Provider Demographics
NPI:1588813885
Name:WAGENKNECHT, VIRGINIA (LAC)
Entity Type:Individual
Prefix:MISS
First Name:VIRGINIA
Middle Name:
Last Name:WAGENKNECHT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 S CLARK DR
Mailing Address - Street 2:PH3
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3274
Mailing Address - Country:US
Mailing Address - Phone:954-682-0651
Mailing Address - Fax:
Practice Address - Street 1:9701 W PICO BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-4744
Practice Address - Country:US
Practice Address - Phone:310-230-5489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist