Provider Demographics
NPI:1316041957
Name:T W WAGNER INC
Entity Type:Organization
Organization Name:T W WAGNER INC
Other - Org Name:WAGNER MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:870-561-3300
Mailing Address - Street 1:331 BROAD STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEPANTO
Mailing Address - State:AR
Mailing Address - Zip Code:72354
Mailing Address - Country:US
Mailing Address - Phone:870-475-3825
Mailing Address - Fax:870-475-3823
Practice Address - Street 1:331 BROAD STREET
Practice Address - Street 2:SUITE B
Practice Address - City:LEPANTO
Practice Address - State:AR
Practice Address - Zip Code:72354
Practice Address - Country:US
Practice Address - Phone:870-475-3825
Practice Address - Fax:870-475-3823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health