Provider Demographics
NPI:1770750010
Name:WAGNER INDUSTRIES, INC.
Entity type:Organization
Organization Name:WAGNER INDUSTRIES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MS
Authorized Official - Phone:860-405-5555
Mailing Address - Street 1:540 ROUTE 148
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419-1107
Mailing Address - Country:US
Mailing Address - Phone:860-405-5555
Mailing Address - Fax:
Practice Address - Street 1:5 WATER ST
Practice Address - Street 2:C/O OPTIMYSTIC
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2507
Practice Address - Country:US
Practice Address - Phone:860-536-1313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01698Medicare PIN