Provider Demographics
NPI:1376618785
Name:WAGUESPACK, JOHN RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:WAGUESPACK
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:PO BOX 2516
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470
Mailing Address - Country:US
Mailing Address - Phone:504-289-4544
Mailing Address - Fax:504-832-8149
Practice Address - Street 1:722 PHOSPHOR AVE
Practice Address - Street 2:
Practice Address - City:MATAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70005
Practice Address - Country:US
Practice Address - Phone:504-289-4344
Practice Address - Fax:504-832-8149
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA408111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA59394Medicare ID - Type Unspecified
T20068Medicare UPIN