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General NPI Number Information
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NPI Number | 1205062437
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Entity Type | Organization
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Legal Business Name | WILD MEDICAL
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Dates
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Enumeration Date | 06/02/2009
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Last Update Date | 07/19/2010
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Provider Practice Location Address
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Address Line | 2821 KAVANAUGH BLVD STE 1C
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City | LITTLE ROCK
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State | AR
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Zip | 72205-3868
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Country | US
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Telephone | 501-235-8978
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Fax | 501-325-3059
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Provider Business Mailing Address
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Address Line | 2821 KAVANAUGH BLVD STE 1C
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City | LITTLE ROCK
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State | AR
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Zip | 72205-3868
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Country | US
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Telephone | 501-235-8978
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Fax | 501-325-3059
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Authorized Official
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Title or Position | C.E.O.
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Name | STEPHEN WILD
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Credential |
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Telephone | 501-613-4724
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | MG00958
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License Number State | AR
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