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General NPI Number Information
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NPI Number | 1790637916
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Entity Type | Organization
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Legal Business Name | GREATER PT LLC
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Dates
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Enumeration Date | 02/11/2026
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Last Update Date | 02/11/2026
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Provider Practice Location Address
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Address Line | 5400 GARY ST
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City | FORT SMITH
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State | AR
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Zip | 72903-4744
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Country | US
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Telephone | 918-658-0975
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Fax |
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Provider Business Mailing Address
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Address Line | 701 SOUTH ST
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City | MOUNTAIN HOME
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State | AR
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Zip | 72653-4452
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICAIAH WAGNER
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Credential | PT,DPT
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Telephone | 918-658-0975
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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