Provider Demographics
NPI:1457117905
Name:BAGWELL, TIFFANY M (DC)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:M
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-2201
Mailing Address - Country:US
Mailing Address - Phone:415-788-8700
Mailing Address - Fax:
Practice Address - Street 1:1365 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94158-2201
Practice Address - Country:US
Practice Address - Phone:415-788-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35212111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor