Provider Demographics
NPI:1730196569
Name:VAN WAGENEN, JAMES B (DC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:B
Last Name:VAN WAGENEN
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 1:1861 SORRELL CIR.
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95675
Mailing Address - Country:US
Mailing Address - Phone:512-698-2602
Mailing Address - Fax:916-725-0923
Practice Address - Street 1:6024 SAN JUAN AVE.
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-5643
Practice Address - Country:US
Practice Address - Phone:916-725-7533
Practice Address - Fax:916-725-0923
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6495111N00000X
CADC-30427111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC-30427OtherCALIF. LICENSE
TXC06050433Medicaid
TXTX6495OtherSTATE LICENSE
U51082Medicare UPIN
605043Medicare ID - Type Unspecified