1467761148 NPI number — MR. BRAD AFTON WALKER BS, LPTA

Table of content: MR. BRAD AFTON WALKER BS, LPTA (NPI 1467761148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467761148 NPI number — MR. BRAD AFTON WALKER BS, LPTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKER
Provider First Name:
BRAD
Provider Middle Name:
AFTON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BS, LPTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1467761148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13 EXECUTIVE DR
Provider Second Line Business Mailing Address:
SUITE 18
Provider Business Mailing Address City Name:
FAIRVIEW HEIGHTS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62208-1342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-624-8105
Provider Business Mailing Address Fax Number:
618-624-8214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13 EXECUTIVE DR
Provider Second Line Business Practice Location Address:
SUITE 18
Provider Business Practice Location Address City Name:
FAIRVIEW HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62208-1342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-624-8105
Provider Business Practice Location Address Fax Number:
618-624-8214
Provider Enumeration Date:
09/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  160-002920 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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