Provider Demographics
NPI:1780690289
Name:MAIN, WALTER R (DC)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:R
Last Name:MAIN
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 1:401 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-2636
Mailing Address - Country:US
Mailing Address - Phone:843-537-8200
Mailing Address - Fax:
Practice Address - Street 1:401 MARKET ST
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-2636
Practice Address - Country:US
Practice Address - Phone:843-537-8200
Practice Address - Fax:843-537-8444
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4068111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7862458OtherAETNA INSURANCE
IL048240OtherHEALTH ALLIANCE
IL5722676OtherBLUE CROSS/BLUE SHIELD IN
IL048240OtherHEALTH ALLIANCE
IL7862458OtherAETNA INSURANCE