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General NPI Number Information
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NPI Number | 1457495392
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Entity Type | Organization
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Legal Business Name | WAGNER FAMILY CHIROPRACTIC PC
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Dates
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Enumeration Date | 02/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3023 S HARVARD AVE SUITE B
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City | TULSA
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State | OK
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Zip | 74114-6139
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Country | US
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Telephone | 918-742-2094
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Fax | 918-742-2095
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Provider Business Mailing Address
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Address Line | 3023 S HARVARD AVE SUITE B
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City | TULSA
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State | OK
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Zip | 74114-6139
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Country | US
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Telephone | 918-742-2094
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Fax | 918-742-2095
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Authorized Official
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Title or Position | OWNER
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Name | TIMOTHY A WAGNER
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Credential | DC
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Telephone | 918-742-2094
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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 | 3225
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License Number State | OK
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