Provider Demographics
NPI:1811993009
Name:WAGGONER, TERRANCE R (DC)
Entity type:Individual
Prefix:
First Name:TERRANCE
Middle Name:R
Last Name:WAGGONER
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 1:8015 W US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:SHIPSHEWANA
Mailing Address - State:IN
Mailing Address - Zip Code:46565-9482
Mailing Address - Country:US
Mailing Address - Phone:260-768-4333
Mailing Address - Fax:260-768-4333
Practice Address - Street 1:8015 W US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565-9482
Practice Address - Country:US
Practice Address - Phone:260-768-4333
Practice Address - Fax:260-768-4333
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001068A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN350055622OtherRR/TRAVELERS MEDICARE
IN100113980AMedicaid
IN100113980AMedicaid
IN227650AMedicare PIN