Provider Demographics
NPI:1730678038
Name:WAGNER PT & PERFORMANCE LLC
Entity Type:Organization
Organization Name:WAGNER PT & PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:626-221-2628
Mailing Address - Street 1:376 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-2705
Mailing Address - Country:US
Mailing Address - Phone:626-221-2628
Mailing Address - Fax:
Practice Address - Street 1:290 BEDFORD ST
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347
Practice Address - Country:US
Practice Address - Phone:508-938-9787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1346-AH-PF261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy