Provider Demographics
NPI:1275060873
Name:WALTERS, COREY WILLIAM
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:WILLIAM
Last Name:WALTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 34TH ST S STE C
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2215
Mailing Address - Country:US
Mailing Address - Phone:701-239-7125
Mailing Address - Fax:
Practice Address - Street 1:461 34TH ST S STE C
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2215
Practice Address - Country:US
Practice Address - Phone:701-239-7125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator