Provider Demographics
NPI:1366616757
Name:WAGNER FAMILY CHIROPRACTIC CENTER, PS
Entity type:Organization
Organization Name:WAGNER FAMILY CHIROPRACTIC CENTER, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-692-3800
Mailing Address - Street 1:9615 LEVIN RD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7666
Mailing Address - Country:US
Mailing Address - Phone:360-692-3800
Mailing Address - Fax:360-692-3700
Practice Address - Street 1:9615 LEVIN RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7666
Practice Address - Country:US
Practice Address - Phone:360-692-3800
Practice Address - Fax:360-692-3700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003618111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty