MEDICARE: WAGNON PHYSICAL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1265150601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAGNON PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	5500 CENTRAL AVE STE A
Second Line	:
City	:	HOT SPRINGS
State	:	AR
Zip	:	71913-9712
Country	:	US
Telephone Number	:	501-701-4339
Fax Number	:	501-701-4246

Provider Business Practice Location Address
First Line	:	5500 CENTRAL AVE STE A
Second Line	:
City	:	HOT SPRINGS
State	:	AR
Zip	:	71913-9712
Country	:	US
Telephone Number	:	501-701-4339
Fax Number	:	501-701-4246

Authorized Official
Title or Position	:	OPERATIONS DIRECTOR
Name	:	WILLIAM SAUNDERS
Credential	:
Telephone Number	:	501-701-4339

Provider Enumeration Date	:	08/22/2022
Last Update Date	:	12/22/2022

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