MEDICARE: JWIGGINSBUSINESSINABOX

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1831828383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JWIGGINSBUSINESSINABOX

Provider Business Mailing Address
First Line	:	7917 SUTTONVIEW DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-5236
Country	:	US
Telephone Number	:	413-222-3267
Fax Number	:

Provider Business Practice Location Address
First Line	:	2722 CATALINA AVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28206-2237
Country	:	US
Telephone Number	:	413-222-3267
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JADA MAHOGANY WIGGINS
Credential	:
Telephone Number	:	413-222-3267

Provider Enumeration Date	:	06/09/2022
Last Update Date	:	08/04/2022

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