| Organization Name: | T W WAGNER INC |
| NPI Number: | 1316041957 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TOMMY W WAGNER (OWNER) |
| Mailing Address: | 331 Broad Street Suite B Lepanto |
| State: | AR US |
| Postal Code: | 72354 |
| Phone Number: | 8704753825 |
| Fax Number: | 8704753823 |
| NPI Enumeration Date: | 09/12/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR1300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rural Health |
| Taxonomy Definition: | |