=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124158167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARED A VANWAGNER D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 08/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7550 MISSION HILLS DR SUITE 316
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34119-9603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-775-6416
-----------------------------------------------------
Fax | 239-775-6407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7550 MISSION HILLS DR SUITE 316
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34119-9603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-775-6416
-----------------------------------------------------
Fax | 239-775-6407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301009240
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH10841
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------