Healthcare Provider Details

I. General information

NPI: 1811597792
Provider Name (Legal Business Name): ALAN WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 S TOWNSHIP ROAD 113
TIFFIN OH
44883-9791
US

IV. Provider business mailing address

795 S TOWNSHIP ROAD 113
TIFFIN OH
44883-9791
US

V. Phone/Fax

Practice location:
  • Phone: 419-987-4440
  • Fax:
Mailing address:
  • Phone: 419-987-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number7401270
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number7401270
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number7401270
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number7401270
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number7401270
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: