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General NPI Number Information
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NPI Number | 1235418666
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Entity Type | Organization
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Legal Business Name | WAGENBLAST CHIROPRACTIC, PLLC
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Dates
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Enumeration Date | 08/16/2011
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Last Update Date | 08/16/2011
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Provider Practice Location Address
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Address Line | 102 E MAIN ST SUITE A
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City | ROUND ROCK
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State | TX
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Zip | 78664-5200
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Country | US
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Telephone | 512-284-9278
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Fax | 512-284-9283
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Provider Business Mailing Address
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Address Line | 1111 REMINGTON DR
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City | LEANDER
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State | TX
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Zip | 78641-7799
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Country | US
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Telephone | 512-507-6681
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Fax | 512-284-9283
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Authorized Official
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Title or Position | OWNER
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Name | DR. SETH ANDREW WAGENBLAST
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Credential | DC
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Telephone | 512-507-6681
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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 | 9995
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 9995
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 9995
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License Number State | TX
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