MEDICARE: WAGNER CHIROPRACTIC PA

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
1	111N00000X	Chiropractor	CH8955	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	96871	OTHER	FL	BLUE CROSS BLUE SHIELD FL

General Provider Information

NPI Number	:	1346420114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAGNER CHIROPRACTIC PA

Provider Business Mailing Address
First Line	:	2755 S BAY ST
Second Line	:	SUITE D
City	:	EUSTIS
State	:	FL
Zip	:	32726-6587
Country	:	US
Telephone Number	:	352-589-5443
Fax Number	:	352-589-5549

Provider Business Practice Location Address
First Line	:	2755 S BAY ST
Second Line	:	SUITE D
City	:	EUSTIS
State	:	FL
Zip	:	32726-6587
Country	:	US
Telephone Number	:	352-589-5443
Fax Number	:	352-589-5549

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. RAMAH J WAGNER
Credential	:	D.C.
Telephone Number	:	352-589-5543

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	11/09/2007

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