Healthcare Provider Details

I. General information

NPI: 1154624096
Provider Name (Legal Business Name): WAGNER CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S MAIN PLAZA
HENDRICKS MN
56136-1244
US

IV. Provider business mailing address

1200 E 25TH ST
HIBBING MN
55746-3897
US

V. Phone/Fax

Practice location:
  • Phone: 507-275-6932
  • Fax: 507-275-1212
Mailing address:
  • Phone: 218-312-3002
  • Fax: 218-312-3003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5428
License Number StateMN

VIII. Authorized Official

Name: JOSH D WAGNER
Title or Position: OWNER
Credential: DC
Phone: 507-275-6932