Basic Information
| Provider Information | |||||||||
| NPI: | 1841442811 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAGNON PLACE HEALTH FACILITIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2908 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721434802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013053153 | ||||||||
| FaxNumber: | 5012793695 | ||||||||
| Practice Location | |||||||||
| Address1: | 1440 EAST CHURCH STREET | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702266766 | ||||||||
| FaxNumber: | 8702267430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | WIGGINS | ||||||||
| AuthorizedOfficialFirstName: | JOEY | ||||||||
| AuthorizedOfficialMiddleName: | MARTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5013053153 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 174597311 | 05 | AR | MEDICAID |