Provider Demographics
NPI:1275609331
Name:WALTER CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:WALTER CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:540-362-0811
Mailing Address - Street 1:5219 PETERS CREEK RD NW
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-3864
Mailing Address - Country:US
Mailing Address - Phone:540-362-0811
Mailing Address - Fax:540-362-5025
Practice Address - Street 1:5219 PETERS CREEK RD NW
Practice Address - Street 2:SUITE 5
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-3864
Practice Address - Country:US
Practice Address - Phone:540-362-0811
Practice Address - Fax:540-362-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000425111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT90929Medicare UPIN