Provider Demographics
NPI:1376191635
Name:VANWAGNER INC
Entity Type:Organization
Organization Name:VANWAGNER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:VANWAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:804-564-6110
Mailing Address - Street 1:10857 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3312
Mailing Address - Country:US
Mailing Address - Phone:804-270-3000
Mailing Address - Fax:804-270-3004
Practice Address - Street 1:10857 W BROAD ST
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3312
Practice Address - Country:US
Practice Address - Phone:804-270-3000
Practice Address - Fax:804-270-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty