Provider Demographics
NPI:1689661944
Name:WALLER, RICHARD R JR (DC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:WALLER
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 1:563 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01740-1300
Mailing Address - Country:US
Mailing Address - Phone:978-779-5539
Mailing Address - Fax:978-779-6034
Practice Address - Street 1:563 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:MA
Practice Address - Zip Code:01740-1300
Practice Address - Country:US
Practice Address - Phone:978-779-5539
Practice Address - Fax:978-779-6034
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA881111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA706089OtherTUFTS HEALTH PLAN
MAWAY35658OtherBLUE CROSS/BLUE SHIELD
T58319Medicare UPIN
Y3565835Medicare ID - Type Unspecified