Provider Demographics
NPI:1326620402
Name:WALLS, DILLAN
Entity Type:Individual
Prefix:
First Name:DILLAN
Middle Name:
Last Name:WALLS
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 1:24 BARRING PL
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8828
Mailing Address - Country:US
Mailing Address - Phone:386-864-3981
Mailing Address - Fax:386-585-4627
Practice Address - Street 1:24 BARRING PL
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8828
Practice Address - Country:US
Practice Address - Phone:386-624-1641
Practice Address - Fax:386-585-4627
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLW420-172-98-282-0343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)