Healthcare Provider Details

I. General information

NPI: 1114188679
Provider Name (Legal Business Name): BAGLEY FAMILY CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W HIGH ST
HICKSVILLE OH
43526-1083
US

IV. Provider business mailing address

501 W HIGH ST
HICKSVILLE OH
43526-1083
US

V. Phone/Fax

Practice location:
  • Phone: 419-542-8247
  • Fax: 419-542-6726
Mailing address:
  • Phone: 419-542-8247
  • Fax: 419-542-6726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3696
License Number StateOH

VIII. Authorized Official

Name: DR. RYAN DAVID BAGLEY
Title or Position: MEMBER
Credential: D.C.
Phone: 419-542-8247