Healthcare Provider Details

I. General information

NPI: 1790637916
Provider Name (Legal Business Name): GREATER PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2026
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GARY ST
FORT SMITH AR
72903-4744
US

IV. Provider business mailing address

701 SOUTH ST
MOUNTAIN HOME AR
72653-4452
US

V. Phone/Fax

Practice location:
  • Phone: 918-658-0975
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: MICAIAH WAGNER
Title or Position: OWNER
Credential: PT,DPT
Phone: 918-658-0975