Healthcare Provider Details

I. General information

NPI: 1417424524
Provider Name (Legal Business Name): WINGFIELD PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 S MADISON ST
DE WITT AR
72042-3003
US

IV. Provider business mailing address

PO BOX 309
DE WITT AR
72042-0309
US

V. Phone/Fax

Practice location:
  • Phone: 870-344-1642
  • Fax:
Mailing address:
  • Phone: 870-344-1642
  • Fax: 833-234-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER KATE WINGFIELD
Title or Position: PHYSICAL THERAPY
Credential: PT
Phone: 870-344-1642