Provider Demographics
NPI:1659605541
Name:WAGNER, KEITH ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALLEN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:KEITH
Other - Middle Name:ALLEN
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:5716 AMMONS ST
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-2424
Mailing Address - Country:US
Mailing Address - Phone:303-940-0666
Mailing Address - Fax:303-940-6320
Practice Address - Street 1:5716 AMMONS ST
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-2424
Practice Address - Country:US
Practice Address - Phone:303-940-0666
Practice Address - Fax:303-940-6320
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3161111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor