Provider Demographics
NPI:1730635715
Name:WALLE, BETELEHAM
Entity Type:Individual
Prefix:
First Name:BETELEHAM
Middle Name:
Last Name:WALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 PECKS WOODS TURN
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-8426
Mailing Address - Country:US
Mailing Address - Phone:612-205-1408
Mailing Address - Fax:
Practice Address - Street 1:3200 PECKS WOODS TURN
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-8426
Practice Address - Country:US
Practice Address - Phone:612-205-1408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)