Provider Demographics
NPI:1124315775
Name:WALLER CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:WALLER CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-550-6190
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty