Provider Demographics
NPI:1205289139
Name:WALTHALL, CHARLES DUANE (PTA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DUANE
Last Name:WALTHALL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 W ARIZONA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-5709
Mailing Address - Country:US
Mailing Address - Phone:720-938-5907
Mailing Address - Fax:
Practice Address - Street 1:5353 E YALE AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-6902
Practice Address - Country:US
Practice Address - Phone:303-757-1209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13894174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist