Organization
ALL INJURY & DIAGNOSTIC CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHNATHAN LIVINGSTON WAGNER BS,DC (OWNER)
(386) 290-2324
Entity
Organization
Contact information
Practice address
125 MASON AVE STE A, DAYTONA BEACH, FL 32117-5017
(386) 252-0658
(386) 313-0304
Mailing address
125 MASON AVE STE A, DAYTONA BEACH, FL 32117-5017
(386) 252-0658
(386) 313-0304
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
—
—
247100000X
Radiologic Technologist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1881628220
NPI TYPE 1
FL
Enumeration date
01/07/2019
Last updated
01/07/2019
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