Provider Demographics
NPI:1790921856
Name:A L WAGNER FAMILY CHIROPRACTIC PC
Entity Type:Organization
Organization Name:A L WAGNER FAMILY CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-557-7455
Mailing Address - Street 1:4719 SHELBURNE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-5677
Mailing Address - Country:US
Mailing Address - Phone:701-557-7455
Mailing Address - Fax:
Practice Address - Street 1:4719 SHELBURNE ST STE 2
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5677
Practice Address - Country:US
Practice Address - Phone:701-557-7455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND830111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty