Provider Demographics
NPI:1134588288
Name:WAGNER FAMILY CHIROPRACTIC SC
Entity type:Organization
Organization Name:WAGNER FAMILY CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-968-0464
Mailing Address - Street 1:N110 BRUX RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-9439
Mailing Address - Country:US
Mailing Address - Phone:920-968-0464
Mailing Address - Fax:920-968-0482
Practice Address - Street 1:N110 BRUX RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-9439
Practice Address - Country:US
Practice Address - Phone:920-968-0464
Practice Address - Fax:920-968-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13327-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty