Provider Demographics
NPI:1679236400
Name:WAGONER HOLDINGS PA
Entity Type:Organization
Organization Name:WAGONER HOLDINGS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:JONATHON
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:260-573-1249
Mailing Address - Street 1:1408 WOODLAND HILLS TRL APT 204
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-1778
Mailing Address - Country:US
Mailing Address - Phone:260-573-1249
Mailing Address - Fax:
Practice Address - Street 1:851 WAKE FOREST BUSINESS PARK STE E
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7366
Practice Address - Country:US
Practice Address - Phone:260-573-1249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5176OtherNC STATE CHIROPRACTIC LICENSE NUMBER