Provider Demographics
NPI:1659479772
Name:WALTERS, JEFFREY RICHARD (CH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RICHARD
Last Name:WALTERS
Suffix:
Gender:M
Credentials:CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3583 GATWICK MANOR LN
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8408
Mailing Address - Country:US
Mailing Address - Phone:321-549-7097
Mailing Address - Fax:
Practice Address - Street 1:3583 GATWICK MANOR LN
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8408
Practice Address - Country:US
Practice Address - Phone:321-549-7097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10505111N00000X, 111N00000X
CO5611111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
V00989Medicare UPIN
COC545918Medicare PIN