Provider Demographics
NPI:1811000912
Name:DAVID R. WAGNER, DC, PLLC
Entity Type:Organization
Organization Name:DAVID R. WAGNER, DC, PLLC
Other - Org Name:SLAUGHTER LANE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHEIF OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-280-6212
Mailing Address - Street 1:2110 SLAUGHTER LN W STE 145
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5938
Mailing Address - Country:US
Mailing Address - Phone:512-280-6212
Mailing Address - Fax:512-535-3413
Practice Address - Street 1:2110 SLAUGHTER LN W STE 145
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5938
Practice Address - Country:US
Practice Address - Phone:512-280-6212
Practice Address - Fax:512-535-3413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5492261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F2313Medicare PIN