MEDICARE: WAGNER CHIROPRACTIC

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	:	1932405644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAGNER CHIROPRACTIC

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	:	PRESIDENT
Name	:	DR. EDWARD WAGNER
Credential	:
Telephone Number	:	310-230-2145

Provider Enumeration Date	:	01/28/2011
Last Update Date	:	01/28/2011

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