Provider Demographics
NPI:1750689196
Name:LISA A. WAGNER CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:LISA A. WAGNER CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:626-852-2822
Mailing Address - Street 1:625 E ARROW HWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6521
Mailing Address - Country:US
Mailing Address - Phone:626-852-2822
Mailing Address - Fax:626-852-2824
Practice Address - Street 1:625 E ARROW HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6521
Practice Address - Country:US
Practice Address - Phone:626-852-2822
Practice Address - Fax:626-852-2824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23398261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC23398Medicare PIN