Provider Demographics
NPI:1508847997
Name:WAGNER, DAVID SCOTT (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SCOTT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31285 TEMECULA PKWY STE 260
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-6830
Mailing Address - Country:US
Mailing Address - Phone:951-303-8486
Mailing Address - Fax:951-303-3357
Practice Address - Street 1:31285 TEMECULA PKWY STE 260
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-6830
Practice Address - Country:US
Practice Address - Phone:951-303-8486
Practice Address - Fax:951-303-3357
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU88885Medicare UPIN
CADC0281950Medicare ID - Type Unspecified