| NPI | 1932672540 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOHNATHAN LIVINGSTON WAGNER Owner 386-290-2324 |
| Organization Subpart ? | No |
| Primary Taxonomy | 111N00000X Chiropractor |
| Additional Taxonomies | 247100000X Radiologic Technologist |
| Enumeration Date | 2019-01-07 |
| Last Update Date | 2019-01-07 |