Provider Demographics
NPI:1639608094
Name:WALLS, ANTHONY LEODIS JR
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:LEODIS
Last Name:WALLS
Suffix:JR
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 1:8732 N MEYER RD
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-4684
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8732 N MEYER RD
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854
Practice Address - Country:US
Practice Address - Phone:208-819-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer