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General NPI Number Information
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NPI Number | 1134773971
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Entity Type | Organization
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Legal Business Name | SAN CLEMENTE VITALITY CENTER INC.
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Dates
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Enumeration Date | 07/30/2019
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Last Update Date | 07/30/2019
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Provider Practice Location Address
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Address Line | 647 CAMINO DE LOS MARES STE 218
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City | SAN CLEMENTE
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State | CA
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Zip | 92673-2807
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Country | US
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Telephone | 949-441-7755
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Fax | 949-598-9990
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Provider Business Mailing Address
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Address Line | 15520 ROCKFIELD BLVD #A200
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City | IRVINE
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State | CA
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Zip | 92618-6705
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Country | US
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Telephone | 949-598-9999
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Fax | 949-598-9990
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | BURTON WAGNER
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Credential | D.C.
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Telephone | 949-441-7755
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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 |
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License Number State |
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