Provider Demographics
NPI:1518984509
Name:FAUSNAUGHT, WALTER RONALD JR (DC)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:RONALD
Last Name:FAUSNAUGHT
Suffix:JR
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 1:1509 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-2323
Mailing Address - Country:US
Mailing Address - Phone:931-685-0040
Mailing Address - Fax:931-685-0045
Practice Address - Street 1:1509 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-2323
Practice Address - Country:US
Practice Address - Phone:931-685-0040
Practice Address - Fax:931-685-0045
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001897111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU71115Medicare UPIN