MEDICARE: ALEX WAGNER, LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1841805306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALEX WAGNER, LLC

Provider Business Mailing Address
First Line	:	1864 LAKESHORE DR STE A
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-1607
Country	:	US
Telephone Number	:	231-755-1648
Fax Number	:	231-755-5279

Provider Business Practice Location Address
First Line	:	1864 LAKESHORE DR STE A
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-1607
Country	:	US
Telephone Number	:	231-755-1648
Fax Number	:	231-755-5279

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	TRACEY GABLE-PIPER
Credential	:	CPC
Telephone Number	:	231-755-3647

Provider Enumeration Date	:	09/11/2020
Last Update Date	:	09/15/2020

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