Provider Demographics
NPI:1396544888
Name:COLLISION CHIROPRACTIC LLC
Entity type:Organization
Organization Name:COLLISION CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-343-0585
Mailing Address - Street 1:16356 N THOMPSON PEAK PKWY APT 1089
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2103
Mailing Address - Country:US
Mailing Address - Phone:480-343-0585
Mailing Address - Fax:
Practice Address - Street 1:11 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1313
Practice Address - Country:US
Practice Address - Phone:480-343-0585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty