Provider Demographics
NPI:1932672540
Name:ALL INJURY & DIAGNOSTIC CLINIC LLC
Entity Type:Organization
Organization Name:ALL INJURY & DIAGNOSTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:LIVINGSTON
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:BS,DC
Authorized Official - Phone:386-290-2324
Mailing Address - Street 1:125 MASON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5017
Mailing Address - Country:US
Mailing Address - Phone:386-252-0658
Mailing Address - Fax:386-313-0304
Practice Address - Street 1:125 MASON AVE STE A
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5017
Practice Address - Country:US
Practice Address - Phone:386-252-0658
Practice Address - Fax:386-313-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1881628220OtherNPI TYPE 1