Provider Demographics
NPI:1467595231
Name:NICKELLS, WALTER LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:LEE
Last Name:NICKELLS
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 1:509 E BOWIE ST
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:TX
Mailing Address - Zip Code:78648-3003
Mailing Address - Country:US
Mailing Address - Phone:830-875-5040
Mailing Address - Fax:830-875-5040
Practice Address - Street 1:522 E CROCKETT ST
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:TX
Practice Address - Zip Code:78648-2600
Practice Address - Country:US
Practice Address - Phone:830-875-5040
Practice Address - Fax:830-875-5040
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6943111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU60191Medicare UPIN
TX605382Medicare ID - Type Unspecified