Provider Demographics
NPI:1083894489
Name:ROGER D WALLIS DCPC
Entity Type:Organization
Organization Name:ROGER D WALLIS DCPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PC
Authorized Official - Phone:303-857-6344
Mailing Address - Street 1:419 DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1823
Mailing Address - Country:US
Mailing Address - Phone:303-857-6344
Mailing Address - Fax:303-857-6250
Practice Address - Street 1:419 DENVER AVE
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1823
Practice Address - Country:US
Practice Address - Phone:303-857-6344
Practice Address - Fax:303-857-6250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1509111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC491938Medicare PIN