Provider Demographics
NPI:1164602009
Name:WAGNER, CHAD RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:RICHARD
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2068
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29342-2068
Mailing Address - Country:US
Mailing Address - Phone:864-414-5903
Mailing Address - Fax:864-488-0410
Practice Address - Street 1:115 SOUTHPORT RD STE B
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3814
Practice Address - Country:US
Practice Address - Phone:864-804-6612
Practice Address - Fax:864-488-2216
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3296111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNCS5369086Medicare PIN