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General NPI Number Information
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NPI Number | 1962586305
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Entity Type | Individual
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Provider Name | JOHN BEN VAN WAGNER D.C.
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Gender | Male
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Dates
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Enumeration Date | 10/24/2006
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Last Update Date | 03/13/2020
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Provider Practice Location Address
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Address Line | 80 MAPLE AVE STE. 6
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City | GREAT BARRINGTON
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State | MA
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Zip | 01230-1948
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Country | US
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Telephone | 413-644-8989
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Fax | 413-644-9300
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Provider Business Mailing Address
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Address Line | 531 MAIN ST
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City | GREAT BARRINGTON
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State | MA
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Zip | 01230-2001
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Country | US
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Telephone | 413-644-8989
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Fax | 413-644-9300
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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 | 2279
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License Number State | MA
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