1801982806 NPI number — WAGNER CHIROPRACTIC CLINIC, PC

Table of content: (NPI 1801982806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801982806 NPI number — WAGNER CHIROPRACTIC CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAGNER CHIROPRACTIC CLINIC, PC
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:
WEST OMAHA CHIROPRACTIC & SPORTS INJURY CLINIC
Provider Other Organization Name Type Code:
3
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:
1801982806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2639 S 159TH PLZ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68130-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-334-4700
Provider Business Mailing Address Fax Number:
402-334-0891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2639 S 159TH PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68130-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-334-4700
Provider Business Practice Location Address Fax Number:
402-334-0891
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
TREVOR
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
402-334-4700

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1124 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 36614 . This is a "BLUE CROSS FOR J OWEN-WAG" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 36615 . This is a "BLUE CROSS FOR T WAGNER" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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