Healthcare Provider Details

I. General information

NPI: 1134588288
Provider Name (Legal Business Name): WAGNER FAMILY CHIROPRACTIC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N110 BRUX RD
APPLETON WI
54915-9439
US

IV. Provider business mailing address

N110 BRUX RD
APPLETON WI
54915-9439
US

V. Phone/Fax

Practice location:
  • Phone: 920-968-0464
  • Fax: 920-968-0482
Mailing address:
  • Phone: 920-968-0464
  • Fax: 920-968-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13327-146
License Number StateWI

VIII. Authorized Official

Name: DR. MICHAEL R WAGNER
Title or Position: SECRETARY
Credential: DC
Phone: 920-968-0464