Provider Demographics
NPI:1891038600
Name:WAGEMAN CHIROPRACTIC PC
Entity Type:Organization
Organization Name:WAGEMAN CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT WAGEMAN CHIROPRACTIC PC
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:NED
Authorized Official - Last Name:WAGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-628-3500
Mailing Address - Street 1:720 S RIVER RD
Mailing Address - Street 2:STE. E-103
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5507
Mailing Address - Country:US
Mailing Address - Phone:435-628-3500
Mailing Address - Fax:435-628-0476
Practice Address - Street 1:720 S RIVER RD
Practice Address - Street 2:STE. E-103
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5507
Practice Address - Country:US
Practice Address - Phone:435-628-3500
Practice Address - Fax:435-628-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170227-1202111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty