Healthcare Provider Details

I. General information

NPI: 1225449283
Provider Name (Legal Business Name): WAGGONER CHIROPRACTIC HEALTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 E FILLMORE ST
COLORADO SPRINGS CO
80907-6375
US

IV. Provider business mailing address

824 E FILLMORE ST
COLORADO SPRINGS CO
80907-6375
US

V. Phone/Fax

Practice location:
  • Phone: 719-634-2579
  • Fax: 719-634-2371
Mailing address:
  • Phone: 719-634-2579
  • Fax: 719-634-2371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number2257
License Number StateCO

VIII. Authorized Official

Name: CLINTON C WAGGONER
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 719-634-2579