MEDICARE: WAYNE CHADDOCK RPT

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	PT548	AR

General Provider Information

NPI Number	:	1396839205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAYNE CHADDOCK RPT

Provider Business Mailing Address
First Line	:	2601 CARRINGTON POINTE RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5254
Country	:	US
Telephone Number	:	479-452-8026
Fax Number	:

Provider Business Practice Location Address
First Line	:	7320 ROGERS AVE
Second Line	:	STE. 26
City	:	FORT SMITH
State	:	AR
Zip	:	72903-4164
Country	:	US
Telephone Number	:	479-452-7773
Fax Number	:	479-452-7774

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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Directions to “ WAYNE CHADDOCK RPT” Practice Location

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