Provider Demographics
NPI:1841805306
Name:ALEX WAGNER, LLC
Entity Type:Organization
Organization Name:ALEX WAGNER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GABLE-PIPER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:231-755-3647
Mailing Address - Street 1:1864 LAKESHORE DR STE A
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-1607
Mailing Address - Country:US
Mailing Address - Phone:231-755-1648
Mailing Address - Fax:231-755-5279
Practice Address - Street 1:1864 LAKESHORE DR STE A
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-1607
Practice Address - Country:US
Practice Address - Phone:231-755-1648
Practice Address - Fax:231-755-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-11
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care