Provider Demographics
NPI:1518140029
Name:WALL, HOMER G (DC)
Entity Type:Individual
Prefix:DR
First Name:HOMER
Middle Name:G
Last Name:WALL
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:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80402-0686
Mailing Address - Country:US
Mailing Address - Phone:303-463-9395
Mailing Address - Fax:303-403-4219
Practice Address - Street 1:6355 WARD RD
Practice Address - Street 2:SUITE 420
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-3819
Practice Address - Country:US
Practice Address - Phone:303-463-9395
Practice Address - Fax:303-403-4219
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2073111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor