Provider Demographics
NPI:1538290234
Name:WAGNER, DEADRA L (DC)
Entity Type:Individual
Prefix:
First Name:DEADRA
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 MIAMI RD
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-6055
Mailing Address - Country:US
Mailing Address - Phone:269-208-7031
Mailing Address - Fax:
Practice Address - Street 1:1459 MIAMI RD
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-6055
Practice Address - Country:US
Practice Address - Phone:269-208-7031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009468111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU96645Medicare UPIN
ILK00833Medicare ID - Type Unspecified