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General NPI Number Information
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NPI Number | 1245659507
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Entity Type | Individual
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Provider Name | BURTON WAGNER D.C.
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Gender | Male
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Dates
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Enumeration Date | 04/15/2014
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Last Update Date | 04/20/2015
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Provider Practice Location Address
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Address Line | 647 CAMINO DE LOS MARES STE 220
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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 | 949-616-5470
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Fax |
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Provider Business Mailing Address
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Address Line | 647 CAMINO DE LOS MARES SUITE 220
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City | SAN CLEMENTE
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State | CA
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Zip | 92673-2825
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Country | US
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Telephone | 949-616-5470
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 27883
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License Number State | CA
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