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General NPI Number Information
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NPI Number | 1114414620
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Entity Type | Organization
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Legal Business Name | WAGGENER CHIROPRACTIC AND WELLNESS CENTER LLC
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Dates
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Enumeration Date | 04/19/2018
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Last Update Date | 05/17/2018
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Provider Practice Location Address
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Address Line | 7012 KINGSMILL CT
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City | SPRINGFIELD
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State | IL
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Zip | 62711
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Country | US
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Telephone | 217-679-3637
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Fax |
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Provider Business Mailing Address
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Address Line | 7012 KINGSMILL CT
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City | SPRINGFIELD
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State | IL
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Zip | 62711-7387
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Country | US
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Telephone | 121-767-9363
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Fax |
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | SAMANTHA ARIEL MAYBERRY
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Credential | DC
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Telephone | 217-679-3637
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038012923
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License Number State | IL
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