1750048898 NPI number — WAGENER THERAPY PLC

Table of content: (NPI 1750048898)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750048898 NPI number — WAGENER THERAPY PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAGENER THERAPY PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750048898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4620 E 53RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52807-3620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-216-4209
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6119 DEERE CREEK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52807-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-216-4209
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WAGENER
Authorized Official First Name:
BRANDAL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
224-216-4209

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1760038475 . This is a "WELLMARK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com