Provider Demographics
NPI:1073163713
Name:WAGONER LLC
Entity Type:Organization
Organization Name:WAGONER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUD
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:703-823-3336
Mailing Address - Street 1:4660 KENMORE AVE STE 409
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1306
Mailing Address - Country:US
Mailing Address - Phone:703-823-3336
Mailing Address - Fax:703-823-4684
Practice Address - Street 1:4660 KENMORE AVE STE 409
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1306
Practice Address - Country:US
Practice Address - Phone:703-823-3336
Practice Address - Fax:703-823-4684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty