Provider Demographics
NPI:1689798092
Name:JAY J FITZGERALD DC
Entity Type:Organization
Organization Name:JAY J FITZGERALD DC
Other - Org Name:WAGNER CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-384-5419
Mailing Address - Street 1:109 1ST ST. SW
Mailing Address - Street 2:P.O. BOX 758
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380-0758
Mailing Address - Country:US
Mailing Address - Phone:605-384-5419
Mailing Address - Fax:605-384-5410
Practice Address - Street 1:109 1ST ST. SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-0758
Practice Address - Country:US
Practice Address - Phone:605-384-5419
Practice Address - Fax:605-384-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD840111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7604080Medicaid
SD7604080Medicaid
SDS41227Medicare PIN