Provider Demographics
NPI:1114734969
Name:T W WAGNER INC
Entity type:Organization
Organization Name:T W WAGNER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-561-3300
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-0910
Mailing Address - Country:US
Mailing Address - Phone:870-561-3300
Mailing Address - Fax:
Practice Address - Street 1:730 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:LEPANTO
Practice Address - State:AR
Practice Address - Zip Code:72354-3215
Practice Address - Country:US
Practice Address - Phone:870-475-3825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty