Provider Demographics
NPI:1689355836
Name:WAGNER PERFORMANCE CHIROPRACTIC
Entity Type:Organization
Organization Name:WAGNER PERFORMANCE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MSHP
Authorized Official - Phone:575-607-7097
Mailing Address - Street 1:6404 NANCY ELLEN ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6325
Mailing Address - Country:US
Mailing Address - Phone:575-607-7097
Mailing Address - Fax:
Practice Address - Street 1:1001 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79102-3201
Practice Address - Country:US
Practice Address - Phone:806-318-0632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center