Provider Demographics
NPI:1912199449
Name:WALTON CS XII PC
Entity Type:Organization
Organization Name:WALTON CS XII PC
Other - Org Name:MAY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-628-1111
Mailing Address - Street 1:715 LAKEPOINTE CENTRE DR
Mailing Address - Street 2:SUITE 127
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3065
Mailing Address - Country:US
Mailing Address - Phone:618-628-1111
Mailing Address - Fax:618-628-9053
Practice Address - Street 1:715 LAKEPOINTE CENTRE DR
Practice Address - Street 2:SUITE 127
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3065
Practice Address - Country:US
Practice Address - Phone:618-628-1111
Practice Address - Fax:618-628-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08232044OtherBLUE CROSS BLUE SHIELD
IL08232044OtherBLUE CROSS BLUE SHIELD