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NPI Code Detail

MEDICARE: LOGAN MITCHELL WAGLER

MEDICARE: LOGAN MITCHELL WAGLER
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
1225100000XPhysical Therapist05014354AIN

General Provider Information

NPI Number : 1821663634
Entity Type Code : Individual
Provider Name (Legal Business Name) : LOGAN MITCHELL WAGLER
Provider Business Mailing Address
First Line : 790 REMINGTON BLVD
Second Line :
City : BOLINGBROOK
State : IL
Zip : 60440-4909
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 10146 MAYSVILLE RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46835-9589
Country : US
Telephone Number : 260-702-3477
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/24/2021
Last Update Date : 12/10/2025

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Directions to “ LOGAN MITCHELL WAGLER ” Practice Location

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