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NPI Code Detail

MEDICARE: KEVIN WAGNER MSPT

MEDICARE: KEVIN WAGNER MSPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist33753CA

General Provider Information

NPI Number : 1306006978
Entity Type Code : Individual
Provider Name (Legal Business Name) : KEVIN WAGNER MSPT
Provider Business Mailing Address
First Line : 4872 MCCONNELL AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90066-6712
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3283 MOTOR AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90034-3709
Country : US
Telephone Number : 310-845-9690
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/16/2008
Last Update Date : 06/23/2008

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Directions to “ KEVIN WAGNER MSPT” Practice Location

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