Healthcare Provider Details

I. General information

NPI: 1225103476
Provider Name (Legal Business Name): RICHARD D WAGNER JR. PT CSCS VCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 CHEYENNE CT
GRAFTON WI
53024-0368
US

IV. Provider business mailing address

1710 MALIBU DR
CEDARBURG WI
53012-9713
US

V. Phone/Fax

Practice location:
  • Phone: 262-375-1075
  • Fax: 262-375-4975
Mailing address:
  • Phone: 262-618-4787
  • Fax: 262-375-4975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5865024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: