Provider Demographics
NPI:1962586305
Name:VAN WAGNER, JOHN BEN (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BEN
Last Name:VAN WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-2001
Mailing Address - Country:US
Mailing Address - Phone:413-644-8989
Mailing Address - Fax:413-644-9300
Practice Address - Street 1:80 MAPLE AVE
Practice Address - Street 2:STE. 6
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1948
Practice Address - Country:US
Practice Address - Phone:413-644-8989
Practice Address - Fax:413-644-9300
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2279111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45308Medicare ID - Type Unspecified