Provider Demographics
NPI:1811973365
Name:IALACCI, WALTER R (DC)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:R
Last Name:IALACCI
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 1:1080 DAY HILL RD STE 105
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1781
Mailing Address - Country:US
Mailing Address - Phone:860-688-6699
Mailing Address - Fax:860-683-2113
Practice Address - Street 1:1060 DAY HILL RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095
Practice Address - Country:US
Practice Address - Phone:860-688-6699
Practice Address - Fax:860-683-2113
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000459111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004134467Medicaid