Provider Demographics
NPI:1457495392
Name:WAGNER FAMILY CHIROPRACTIC PC
Entity Type:Organization
Organization Name:WAGNER FAMILY CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-742-2094
Mailing Address - Street 1:3023 S HARVARD AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-6139
Mailing Address - Country:US
Mailing Address - Phone:918-742-2094
Mailing Address - Fax:918-742-2095
Practice Address - Street 1:3023 S HARVARD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-6139
Practice Address - Country:US
Practice Address - Phone:918-742-2094
Practice Address - Fax:918-742-2095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3225111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty