=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144417957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WARD W. WAGNER D.C., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2007
-----------------------------------------------------
Last Update Date | 09/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4618 MEADOWS LN
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89107-2956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-877-7777
-----------------------------------------------------
Fax | 702-822-2406
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4618 MEADOWS LN
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89107-2956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-877-7777
-----------------------------------------------------
Fax | 702-822-2406
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MISS JANEL WAGNER
-----------------------------------------------------
Credential | NONE
-----------------------------------------------------
Telephone | 702-877-7777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | B885
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------