Provider Demographics
NPI:1346889318
Name:WALLER, VIRGIL
Entity Type:Individual
Prefix:
First Name:VIRGIL
Middle Name:
Last Name:WALLER
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 1:10429 INTERNATIONAL BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94603-3221
Mailing Address - Country:US
Mailing Address - Phone:510-777-8448
Mailing Address - Fax:
Practice Address - Street 1:10429 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94603-3221
Practice Address - Country:US
Practice Address - Phone:510-777-8448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA42287164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician