Provider Demographics
NPI:1568705176
Name:JAMEY P. WAGNER P.C.
Entity Type:Organization
Organization Name:JAMEY P. WAGNER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMEY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:256-864-8470
Mailing Address - Street 1:8103 HIGHWAY 72 W
Mailing Address - Street 2:SUITE C
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-9528
Mailing Address - Country:US
Mailing Address - Phone:256-864-8470
Mailing Address - Fax:256-864-8470
Practice Address - Street 1:8103 HIGHWAY 72 W
Practice Address - Street 2:SUITE C
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9528
Practice Address - Country:US
Practice Address - Phone:256-864-8470
Practice Address - Fax:256-864-8470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1765111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000046363Medicare PIN