Healthcare Provider Details

I. General information

NPI: 1205654068
Provider Name (Legal Business Name): WAGNER WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W3173 SPRINGFIELD DR
APPLETON WI
54915-6183
US

IV. Provider business mailing address

W3173 SPRINGFIELD DR
APPLETON WI
54915-6183
US

V. Phone/Fax

Practice location:
  • Phone: 920-533-0771
  • Fax:
Mailing address:
  • Phone: 920-533-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMUEL WAGNER
Title or Position: OWNER/LEAD DOCTOR
Credential: DC
Phone: 262-344-1968