Healthcare Provider Details

I. General information

NPI: 1811993009
Provider Name (Legal Business Name): TERRANCE R WAGGONER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8015 W US HIGHWAY 20
SHIPSHEWANA IN
46565-9482
US

IV. Provider business mailing address

8015 W US HIGHWAY 20
SHIPSHEWANA IN
46565-9482
US

V. Phone/Fax

Practice location:
  • Phone: 260-768-4333
  • Fax: 260-768-4333
Mailing address:
  • Phone: 260-768-4333
  • Fax: 260-768-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08001068A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: