Provider Demographics
NPI:1225449283
Name:WAGGONER CHIROPRACTIC HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:WAGGONER CHIROPRACTIC HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:C
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-634-2579
Mailing Address - Street 1:824 E FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6375
Mailing Address - Country:US
Mailing Address - Phone:719-634-2579
Mailing Address - Fax:719-634-2371
Practice Address - Street 1:824 E FILLMORE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6375
Practice Address - Country:US
Practice Address - Phone:719-634-2579
Practice Address - Fax:719-634-2371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2257261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC27393OtherPTAN