Provider Demographics
NPI:1205146040
Name:ROCKLIN FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:ROCKLIN FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:916-625-0208
Mailing Address - Street 1:4441 GRANITE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2283
Mailing Address - Country:US
Mailing Address - Phone:916-625-0208
Mailing Address - Fax:916-625-0209
Practice Address - Street 1:4441 GRANITE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2283
Practice Address - Country:US
Practice Address - Phone:916-625-0208
Practice Address - Fax:916-625-0209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30897111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty