Provider Demographics
NPI:1346420114
Name:WAGNER CHIROPRACTIC PA
Entity Type:Organization
Organization Name:WAGNER CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-589-5543
Mailing Address - Street 1:2755 S BAY ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6587
Mailing Address - Country:US
Mailing Address - Phone:352-589-5443
Mailing Address - Fax:352-589-5549
Practice Address - Street 1:2755 S BAY ST
Practice Address - Street 2:SUITE D
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6587
Practice Address - Country:US
Practice Address - Phone:352-589-5443
Practice Address - Fax:352-589-5549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8955111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL96871OtherBLUE CROSS BLUE SHIELD FL
FLK9341Medicare PIN
FLV08081Medicare UPIN
96871ZMedicare PIN