1124296314 NPI number — DR MARY A WALTERS

Table of content: (NPI 1124296314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124296314 NPI number — DR MARY A WALTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR MARY A WALTERS
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:
WALTERS FAMILY CHIROPRACTIC CENTER
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:
1124296314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1174 WYOMING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORTY FORT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18704-4016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-288-9444
Provider Business Mailing Address Fax Number:
570-331-7543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1174 WYOMING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORTY FORT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18704-4016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-288-9444
Provider Business Practice Location Address Fax Number:
570-331-7543
Provider Enumeration Date:
02/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WALTERS
Authorized Official First Name:
MARY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-288-9444

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 072962 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1659387678 . This is a "INDV NPI TYPE 1" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: WA181952 . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 181952 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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