1780750844 NPI number — MR. MARK S WALSTROM L.P.C.

Table of content: MR. MARK S WALSTROM L.P.C. (NPI 1780750844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780750844 NPI number — MR. MARK S WALSTROM L.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSTROM
Provider First Name:
MARK
Provider Middle Name:
S
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
L.P.C.
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:
1780750844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
967 SPAULDING AVE SE
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
ADA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49301-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-633-2170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
967 SPAULDING AVE SE
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
ADA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49301-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-633-2170
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006

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: 101YP2500X , with the licence number:  6401003116 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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