Provider Demographics
NPI:1235324823
Name:JL WALSH PA
Entity Type:Organization
Organization Name:JL WALSH PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-565-3687
Mailing Address - Street 1:183 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-1236
Mailing Address - Country:US
Mailing Address - Phone:651-565-3687
Mailing Address - Fax:
Practice Address - Street 1:183 MAIN ST W
Practice Address - Street 2:
Practice Address - City:WABASHA
Practice Address - State:MN
Practice Address - Zip Code:55981-1236
Practice Address - Country:US
Practice Address - Phone:651-565-3687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2607152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND02542OtherMEDICARE RAILROAD
MN6149040001Medicare NSC
MNC05106Medicare PIN