Provider Demographics
NPI:1396839205
Name:CHADDOCK, WAYNE (RPT)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:CHADDOCK
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 CARRINGTON POINTE RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5254
Mailing Address - Country:US
Mailing Address - Phone:479-452-8026
Mailing Address - Fax:
Practice Address - Street 1:7320 ROGERS AVE
Practice Address - Street 2:STE. 26
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4164
Practice Address - Country:US
Practice Address - Phone:479-452-7773
Practice Address - Fax:479-452-7774
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T270Medicare ID - Type Unspecified