1679529010 NPI number — WALNUT LANE MANAGEMENT LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679529010 NPI number — WALNUT LANE MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALNUT LANE MANAGEMENT LLC
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:
Provider Other Organization Name Type Code:
6
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:
1679529010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVELERS REST
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-834-8099
Provider Business Mailing Address Fax Number:
864-834-8108

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 WALNUT LANE
Provider Second Line Business Practice Location Address:
SUITE I
Provider Business Practice Location Address City Name:
TRAVELERS REST
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-834-8099
Provider Business Practice Location Address Fax Number:
864-834-8108
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ST JOHN
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
WYLIE
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
864-834-8099

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1637 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CH1637 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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