Provider Demographics
NPI:1639382369
Name:CARL R. WAGREICH, D.P.M., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CARL R. WAGREICH, D.P.M., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGREICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-373-0521
Mailing Address - Street 1:23451 MADISON ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4763
Mailing Address - Country:US
Mailing Address - Phone:310-373-0521
Mailing Address - Fax:310-791-1691
Practice Address - Street 1:23451 MADISON ST
Practice Address - Street 2:SUITE 230
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4763
Practice Address - Country:US
Practice Address - Phone:310-373-0521
Practice Address - Fax:310-791-1691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2415261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E24150Medicaid
CA000E24150Medicaid
CAW22386Medicare PIN
CA0900790001Medicare NSC