Provider Demographics
NPI:1184724197
Name:WATLEY, MIQUEL (DC)
Entity type:Individual
Prefix:DR
First Name:MIQUEL
Middle Name:
Last Name:WATLEY
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 1:120 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2704
Mailing Address - Country:US
Mailing Address - Phone:502-636-0400
Mailing Address - Fax:502-637-1812
Practice Address - Street 1:120 E OAK ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2704
Practice Address - Country:US
Practice Address - Phone:502-636-0400
Practice Address - Fax:502-637-1812
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4186111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85002848Medicaid
KY50002113OtherPASSPORT
KY85002848Medicaid