Basic Information
| Provider Information | |||||||||
| NPI: | 1093186611 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAGONER HEALTH & REHAB LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WAGONER HEALTH & REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLA VISTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727158462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797156759 | ||||||||
| FaxNumber: | 4797156922 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | WAGONER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744673915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184852203 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2015 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | BRADFORD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4797156759 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH732 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.