Provider Demographics
NPI:1740586395
Name:WAGONER MOBILITY & MEDICAL
Entity Type:Organization
Organization Name:WAGONER MOBILITY & MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-260-4687
Mailing Address - Street 1:1202 N NAVAJO ST
Mailing Address - Street 2:
Mailing Address - City:CHOUTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74337-3700
Mailing Address - Country:US
Mailing Address - Phone:918-527-6404
Mailing Address - Fax:187-735-2918
Practice Address - Street 1:30 ELM DR
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4456
Practice Address - Country:US
Practice Address - Phone:918-260-4687
Practice Address - Fax:187-735-2918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies