Provider Demographics
NPI:1275558207
Name:WALSH, BRIAN L (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:WALSH
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 1:307 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-1743
Mailing Address - Country:US
Mailing Address - Phone:712-732-4063
Mailing Address - Fax:712-732-6383
Practice Address - Street 1:307 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1743
Practice Address - Country:US
Practice Address - Phone:712-732-4063
Practice Address - Fax:712-732-6383
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04334111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA03094Medicaid
IA03094Medicare PIN