Provider Demographics
NPI:1699840660
Name:WALTEMATE WELLNESS CENTER
Entity Type:Organization
Organization Name:WALTEMATE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTEMATE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-688-0477
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:71108-5804
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA749111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA59306Medicare ID - Type Unspecified