Provider Demographics
NPI:1912254152
Name:WALRUS SERVICES, LLC
Entity Type:Organization
Organization Name:WALRUS SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/C.O.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:DOW
Authorized Official - Middle Name:G (GUY)
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:D MIN, M ED
Authorized Official - Phone:321-689-2072
Mailing Address - Street 1:390 S GERONIMO ST
Mailing Address - Street 2:SUITE #104
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-7020
Mailing Address - Country:US
Mailing Address - Phone:850-650-0053
Mailing Address - Fax:850-650-0075
Practice Address - Street 1:390 S GERONIMO ST
Practice Address - Street 2:SUITE #104
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-7020
Practice Address - Country:US
Practice Address - Phone:850-650-0053
Practice Address - Fax:850-650-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL691154496251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691154496Medicaid