Provider Demographics
NPI:1386675262
Name:MELLGREN, WALTER JEAN JR (DC)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JEAN
Last Name:MELLGREN
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:109 N REAGAN ST
Mailing Address - City:WEST
Mailing Address - State:TX
Mailing Address - Zip Code:76691-0475
Mailing Address - Country:US
Mailing Address - Phone:254-826-3737
Mailing Address - Fax:254-826-3769
Practice Address - Street 1:109 N REAGAN ST
Practice Address - Street 2:
Practice Address - City:WEST
Practice Address - State:TX
Practice Address - Zip Code:76691-0475
Practice Address - Country:US
Practice Address - Phone:254-826-3737
Practice Address - Fax:254-826-3769
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2506111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00L71LOtherBCBS
TX85V570Medicare ID - Type Unspecified
T14793Medicare UPIN