Provider Demographics
NPI:1891727269
Name:WALLER, STEPHEN B (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:B
Last Name:WALLER
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:PO BOX 631907
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-0038
Mailing Address - Country:US
Mailing Address - Phone:972-550-6190
Mailing Address - Fax:972-550-6013
Practice Address - Street 1:1121 KINWEST PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3135
Practice Address - Country:US
Practice Address - Phone:972-550-6190
Practice Address - Fax:972-550-6013
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV06867Medicare UPIN
TX611984Medicare PIN