=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720456320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WYNNE ELDER CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2015
-----------------------------------------------------
Last Update Date | 09/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2019 E BROADWAY ST
-----------------------------------------------------
City | FORREST CITY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72335-7881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-633-1977
-----------------------------------------------------
Fax | 870-633-1977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1420
-----------------------------------------------------
City | WYNNE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72396-1420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INCORPORATOR/ORGANIZER
-----------------------------------------------------
Name | MRS. MARGARET PAULETTE MCCLANAHAN
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 870-208-5452
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | PT820
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------