Provider Demographics
NPI:1104250349
Name:THE WIGG CENTER
Entity type:Organization
Organization Name:THE WIGG CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TEEYAUDA
Authorized Official - Middle Name:EVELYN
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:813-508-3639
Mailing Address - Street 1:4943 E 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-4705
Mailing Address - Country:US
Mailing Address - Phone:813-464-4083
Mailing Address - Fax:813-354-3515
Practice Address - Street 1:4943 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-4705
Practice Address - Country:US
Practice Address - Phone:813-464-4083
Practice Address - Fax:813-354-3515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management