Provider Demographics
NPI:1265694012
Name:WALTER M DISE
Entity type:Organization
Organization Name:WALTER M DISE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:DISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-430-5328
Mailing Address - Street 1:34095 N SLATE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85243-3420
Mailing Address - Country:US
Mailing Address - Phone:480-430-5328
Mailing Address - Fax:480-354-7247
Practice Address - Street 1:34095 N SLATE CREEK DR
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85243-3420
Practice Address - Country:US
Practice Address - Phone:480-430-5328
Practice Address - Fax:480-354-7247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9454343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)