Provider Demographics
NPI:1245659507
Name:WAGNER, BURTON (DC)
Entity type:Individual
Prefix:DR
First Name:BURTON
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 CAMINO DE LOS MARES
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2825
Mailing Address - Country:US
Mailing Address - Phone:949-616-5470
Mailing Address - Fax:
Practice Address - Street 1:647 CAMINO DE LOS MARES STE 220
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2807
Practice Address - Country:US
Practice Address - Phone:949-616-5470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27883111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor