Provider Demographics
NPI:1821028325
Name:BAGWELL, TRACY GLEN (DC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:GLEN
Last Name:BAGWELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2227 DRAKE AVENUE
Mailing Address - Street 2:SUITE 13
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805
Mailing Address - Country:US
Mailing Address - Phone:256-880-8833
Mailing Address - Fax:256-880-8838
Practice Address - Street 1:2227 DRAKE AVENUE
Practice Address - Street 2:SUITE 13
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805
Practice Address - Country:US
Practice Address - Phone:256-880-8833
Practice Address - Fax:256-880-8838
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL1224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL71286OtherBLUE CROSS BLUE SHIELD
T92835Medicare UPIN