MEDICARE: EDWARD D 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	11827	CA

General Provider Information

NPI Number	:	1770310690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD D WAGNER DC

Provider Business Mailing Address
First Line	:	17383 W SUNSET BLVD STE A230
Second Line	:
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-4181
Country	:	US
Telephone Number	:	310-230-2145
Fax Number	:	310-230-2152

Provider Business Practice Location Address
First Line	:	17383 W SUNSET BLVD STE A230
Second Line	:
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-4181
Country	:	US
Telephone Number	:	310-230-2145
Fax Number	:	310-230-2152

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

Provider Enumeration Date	:	09/16/2024
Last Update Date	:	09/16/2024

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Directions to “ EDWARD D WAGNER DC” Practice Location

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