Provider Demographics
NPI:1679643506
Name:WALTEMATE, SCOTT AARON (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:AARON
Last Name:WALTEMATE
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 1:8805 JEWELLA AVE
Mailing Address - Street 2:SUITE 219
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108
Mailing Address - Country:US
Mailing Address - Phone:318-688-0477
Mailing Address - Fax:318-688-2376
Practice Address - Street 1:8805 JEWELLA AVE
Practice Address - Street 2:SUITE 219
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71108-5804
Practice Address - Country:US
Practice Address - Phone:318-688-0477
Practice Address - Fax:318-688-2376
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA59306Medicare ID - Type Unspecified