MEDICARE: WISE COUNTY HEALTH SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	0041617	TX

General Provider Information

NPI Number	:	1528112356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE COUNTY HEALTH SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 667
Second Line	:
City	:	BRIDGEPORT
State	:	TX
Zip	:	76426-0667
Country	:	US
Telephone Number	:	940-627-9173
Fax Number	:	940-627-4960

Provider Business Practice Location Address
First Line	:	800 MEDICAL CENTER DR
Second Line	:	STE B
City	:	DECATUR
State	:	TX
Zip	:	76234-3843
Country	:	US
Telephone Number	:	940-627-9173
Fax Number	:	940-627-4960

Authorized Official
Title or Position	:	CEO PRESIDENT
Name	:	MR. RONALD G AMMONS
Credential	:
Telephone Number	:	940-683-6370

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	08/22/2020

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