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General NPI Number Information
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NPI Number | 1871651422
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Entity Type | Organization
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Legal Business Name | PHIL WAGGONER
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1720 18TH AVE
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City | LEWISTON
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State | ID
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Zip | 83501-4047
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Country | US
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Telephone | 208-746-4097
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Fax | 208-746-2294
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Provider Business Mailing Address
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Address Line | 1720 18TH AVE
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City | LEWISTON
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State | ID
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Zip | 83501
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Country | US
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Telephone | 208-746-4097
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Fax | 208-746-2294
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Authorized Official
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Title or Position | BUSINESS OFC MANAGER OWNER
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Name | MRS. DANA K BOYD
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Credential |
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Telephone | 208-746-4097
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 138
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License Number State | ID
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