Provider Demographics
NPI:1932405644
Name:WAGNER CHIROPRACTIC
Entity Type:Organization
Organization Name:WAGNER CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-230-2145
Mailing Address - Street 1:17383 W SUNSET BLVD STE A230
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-4181
Mailing Address - Country:US
Mailing Address - Phone:310-230-2145
Mailing Address - Fax:310-230-2152
Practice Address - Street 1:17383 W SUNSET BLVD STE A230
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-4181
Practice Address - Country:US
Practice Address - Phone:310-230-2145
Practice Address - Fax:310-230-2152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11827111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty