Healthcare Provider Details

I. General information

NPI: 1881628220
Provider Name (Legal Business Name): JOHNATHAN LIVINGSTON WAGNER BS,DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 N RIDGEWOOD AVE
DAYTONA BEACH FL
32114-2170
US

IV. Provider business mailing address

542 N. RIDGEWOOD AVE.
DAYTONA BEACH FL
32114
US

V. Phone/Fax

Practice location:
  • Phone: 386-258-7494
  • Fax: 386-253-0365
Mailing address:
  • Phone: 386-258-7494
  • Fax: 386-253-0365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberCH8731
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: