MEDICARE: MS. ELAINE JANET WAGNER DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	038004140	IL

General Provider Information

NPI Number	:	1417974395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELAINE JANET WAGNER DC

Provider Business Mailing Address
First Line	:	6033 N SHERIDAN RD # CW04S-05
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3003
Country	:	US
Telephone Number	:	773-274-6827
Fax Number	:

Provider Business Practice Location Address
First Line	:	6033 N SHERIDAN RD # CW04S-05
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3003
Country	:	US
Telephone Number	:	773-274-6827
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	07/21/2022

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