Healthcare Provider Details

I. General information

NPI: 1588547103
Provider Name (Legal Business Name): KELVIN KIM WAGLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 07/30/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7178 S RECOVERY RD
FRANCH CAMP CA
95231-9523
US

IV. Provider business mailing address

7178 S RECOVERY RD
FRANCH CAMP CA
95231
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-6208
  • Fax:
Mailing address:
  • Phone: 209-468-6208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number20189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: