Healthcare Provider Details

I. General information

NPI: 1790225720
Provider Name (Legal Business Name): COMFORT WAGNER D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20010 75TH AVE N
CORCORAN MN
55340-9459
US

IV. Provider business mailing address

20010 75TH AVE N
CORCORAN MN
55340-9459
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-4878
  • Fax:
Mailing address:
  • Phone: 763-416-4878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6324
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: