MEDICARE: GREATER PT 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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1790637916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER PT LLC

Provider Business Mailing Address
First Line	:	701 SOUTH ST
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72653-4452
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5400 GARY ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-4744
Country	:	US
Telephone Number	:	918-658-0975
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICAIAH WAGNER
Credential	:	PT,DPT
Telephone Number	:	918-658-0975

Provider Enumeration Date	:	02/11/2026
Last Update Date	:	02/11/2026

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