Provider Demographics
NPI:1225101876
Name:WALTEMATE, ERIC NEIL (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:NEIL
Last Name:WALTEMATE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-2303
Mailing Address - Country:US
Mailing Address - Phone:618-207-4445
Mailing Address - Fax:
Practice Address - Street 1:11628 OLD BALLAS RD STE 112
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7030
Practice Address - Country:US
Practice Address - Phone:314-569-0057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002013828111N00000X
IL038.011402111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU91298Medicare UPIN