Provider Demographics
NPI:1720480189
Name:WAGNER, GERRIT LEE (DC, LAC)
Entity Type:Individual
Prefix:DR
First Name:GERRIT
Middle Name:LEE
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8059
Mailing Address - Country:US
Mailing Address - Phone:909-792-4434
Mailing Address - Fax:909-335-1139
Practice Address - Street 1:620 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8059
Practice Address - Country:US
Practice Address - Phone:909-792-4434
Practice Address - Fax:909-335-1139
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC33062111N00000X
CAAC16183171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist