Provider Demographics
NPI:1821366550
Name:MARK V. WALTERS DC PC
Entity Type:Organization
Organization Name:MARK V. WALTERS DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:V
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-461-1155
Mailing Address - Street 1:316 W MOUNT VERNON BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-1940
Mailing Address - Country:US
Mailing Address - Phone:417-461-1155
Mailing Address - Fax:417-461-1155
Practice Address - Street 1:316 W MOUNT VERNON BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1940
Practice Address - Country:US
Practice Address - Phone:417-461-1155
Practice Address - Fax:417-461-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006467111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO315015486OtherMEDICARE PTAN
MO350039075OtherRAILROAD MEDICARE
MOU64931Medicare UPIN
MO000031498Medicare PIN