Provider Demographics
NPI:1093886764
Name:VAGENAS, GEORGIOS A (DC, QME)
Entity Type:Individual
Prefix:DR
First Name:GEORGIOS
Middle Name:A
Last Name:VAGENAS
Suffix:
Gender:M
Credentials:DC, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 E GREEN ST STE 109
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2431
Mailing Address - Country:US
Mailing Address - Phone:626-793-1255
Mailing Address - Fax:626-793-1279
Practice Address - Street 1:1060 E GREEN ST STE 109
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2431
Practice Address - Country:US
Practice Address - Phone:626-793-1255
Practice Address - Fax:626-793-1279
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 28753111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 28753Medicare ID - Type UnspecifiedCHIROPRACTIC PHYSICIAN
CAV02490Medicare UPIN