Healthcare Provider Details

I. General information

NPI: 1124180351
Provider Name (Legal Business Name): WAGNER & WAGNER PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 COLUMBIA AVE
GLASGOW KY
42141-2903
US

IV. Provider business mailing address

PO BOX 638
GLASGOW KY
42142-0638
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-8323
  • Fax: 270-651-8324
Mailing address:
  • Phone: 270-651-8323
  • Fax: 270-651-8324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD T. WAGNER
Title or Position: PRESIDENT
Credential: O. D.
Phone: 270-651-8323