Provider Demographics
NPI:1972733806
Name:WAGNER CHIROPRACTIC & REHABILITATION P.C.
Entity Type:Organization
Organization Name:WAGNER CHIROPRACTIC & REHABILITATION P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:WARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-673-1443
Mailing Address - Street 1:10 N 400 E
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2919
Mailing Address - Country:US
Mailing Address - Phone:435-673-1443
Mailing Address - Fax:435-673-3868
Practice Address - Street 1:10 N 400 E
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2919
Practice Address - Country:US
Practice Address - Phone:435-673-1443
Practice Address - Fax:435-673-3868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT323936-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5300297360Medicaid
UT000056141Medicare UPIN