Provider Demographics
NPI:1205062437
Name:WILD MEDICAL
Entity type:Organization
Organization Name:WILD MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-613-4724
Mailing Address - Street 1:2821 KAVANAUGH BLVD STE 1C
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3868
Mailing Address - Country:US
Mailing Address - Phone:501-235-8978
Mailing Address - Fax:501-325-3059
Practice Address - Street 1:2821 KAVANAUGH BLVD STE 1C
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3868
Practice Address - Country:US
Practice Address - Phone:501-235-8978
Practice Address - Fax:501-325-3059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMG00958332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR6259680001Medicare NSC