Healthcare Provider Details

I. General information

NPI: 1306832969
Provider Name (Legal Business Name): WAGNON PLACE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 E CHURCH ST
WARREN AR
71671-3528
US

IV. Provider business mailing address

PO BOX 230
WARREN AR
71671-0230
US

V. Phone/Fax

Practice location:
  • Phone: 870-226-6766
  • Fax: 870-226-7430
Mailing address:
  • Phone: 870-226-6766
  • Fax: 870-226-7430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number328
License Number StateAR

VIII. Authorized Official

Name: MS. DOROTHY SUE WAGNON
Title or Position: ADMINISTRATOR OWNER
Credential:
Phone: 870-226-6766