Provider Demographics
NPI:1659445096
Name:TERRANCE R WAGGONER, DC PC
Entity Type:Organization
Organization Name:TERRANCE R WAGGONER, DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNIGONIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-533-2531
Mailing Address - Street 1:8015 W US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:SHIPSHEWANA
Mailing Address - State:IN
Mailing Address - Zip Code:46565-9482
Mailing Address - Country:US
Mailing Address - Phone:260-768-4333
Mailing Address - Fax:260-768-4333
Practice Address - Street 1:8015 W US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565-9482
Practice Address - Country:US
Practice Address - Phone:260-768-4333
Practice Address - Fax:260-768-4333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-18
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN51000148111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112570Medicaid
IN100112570Medicaid