=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336280817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CYCLE FAMILY CHIROPRACTIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 01/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1162 DEXTER ST
-----------------------------------------------------
City | MILAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48160-1162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-439-0100
-----------------------------------------------------
Fax | 734-439-7701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1162 DEXTER ST
-----------------------------------------------------
City | MILAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48160-1162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-439-0100
-----------------------------------------------------
Fax | 734-439-7701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAMES MATTHEW WAGNER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 734-439-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301008349
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------