Provider Demographics
NPI:1225357650
Name:WAGNER CHIROPRACTIC CENTER PLLC
Entity Type:Organization
Organization Name:WAGNER CHIROPRACTIC CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDEN
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:TEETS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-880-2989
Mailing Address - Street 1:4 N RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:PA
Mailing Address - Zip Code:17078-1720
Mailing Address - Country:US
Mailing Address - Phone:717-838-8889
Mailing Address - Fax:
Practice Address - Street 1:4 N RAILROAD ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-1720
Practice Address - Country:US
Practice Address - Phone:717-838-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010272111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty