Provider Demographics
NPI:1841209889
Name:ELEANOR A WALLEN DPM INC
Entity Type:Organization
Organization Name:ELEANOR A WALLEN DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:WALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-980-3383
Mailing Address - Street 1:4418 VINELAND AVENUE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2159
Mailing Address - Country:US
Mailing Address - Phone:818-980-3383
Mailing Address - Fax:818-980-5383
Practice Address - Street 1:4418 VINELAND AVENUE
Practice Address - Street 2:SUITE 215
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2159
Practice Address - Country:US
Practice Address - Phone:818-980-3383
Practice Address - Fax:818-980-5383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3573213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T95609Medicare UPIN
E3573Medicare ID - Type Unspecified