Provider Demographics
NPI:1720820277
Name:WAGERS, KENDRA (LAC DTCM)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:WAGERS
Suffix:
Gender:F
Credentials:LAC DTCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SAN TOMAS AQUINO RD APT 114
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-3300
Mailing Address - Country:US
Mailing Address - Phone:702-845-1560
Mailing Address - Fax:
Practice Address - Street 1:1230 SAN TOMAS AQUINO RD APT 114
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-3300
Practice Address - Country:US
Practice Address - Phone:702-845-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6233171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist