Provider Demographics
NPI:1184762064
Name:WAGGONER CH, CLINTON C
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:C
Last Name:WAGGONER CH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 EAST FILLMORE STEET
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6375
Mailing Address - Country:US
Mailing Address - Phone:719-634-2579
Mailing Address - Fax:719-634-2371
Practice Address - Street 1:824 EAST FILLMORE STEET
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6375
Practice Address - Country:US
Practice Address - Phone:719-634-2579
Practice Address - Fax:719-634-2371
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2257111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC27393Medicare PIN