Provider Demographics
NPI:1902074966
Name:WAGNER CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:WAGNER CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-951-1199
Mailing Address - Street 1:213 N HAYNES
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301
Mailing Address - Country:US
Mailing Address - Phone:406-234-2225
Mailing Address - Fax:406-234-3500
Practice Address - Street 1:213 N HAYNES
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301
Practice Address - Country:US
Practice Address - Phone:406-234-2225
Practice Address - Fax:406-234-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty