Provider Demographics
NPI:1841442811
Name:WAGNON PLACE HEALTH FACILITIES
Entity type:Organization
Organization Name:WAGNON PLACE HEALTH FACILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-305-3153
Mailing Address - Street 1:2908 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4802
Mailing Address - Country:US
Mailing Address - Phone:501-305-3153
Mailing Address - Fax:501-279-3695
Practice Address - Street 1:1440 EAST CHURCH STREET
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671
Practice Address - Country:US
Practice Address - Phone:870-226-6766
Practice Address - Fax:870-226-7430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR174597311Medicaid
AR174597311Medicaid