Provider Demographics
NPI:1942479423
Name:LAFAYETTE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:LAFAYETTE CHIROPRACTIC LLC
Other - Org Name:WAGNER CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:765-448-1674
Mailing Address - Street 1:3778 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4453
Mailing Address - Country:US
Mailing Address - Phone:765-448-1674
Mailing Address - Fax:765-449-0847
Practice Address - Street 1:3778 UNION ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4453
Practice Address - Country:US
Practice Address - Phone:765-448-1674
Practice Address - Fax:765-449-0847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200925750 AMedicaid
IN256900OtherMEDICARE PTAN
IN200925750 AMedicaid