Healthcare Provider Details

I. General information

NPI: 1093700437
Provider Name (Legal Business Name): LEO J WANGLER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 S BROADWAY ST BOX 206
LINTON ND
58552-7025
US

IV. Provider business mailing address

118 S BROADWAY ST BOX 206
LINTON ND
58552-7025
US

V. Phone/Fax

Practice location:
  • Phone: 701-254-4319
  • Fax:
Mailing address:
  • Phone: 701-254-4319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number411
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: