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NPI Code Detail

MEDICARE: KEITH WALTON FAODP

MEDICARE: KEITH WALTON FAODP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101Y00000XCounselor820317MI

General Provider Information

NPI Number : 1881857811
Entity Type Code : Individual
Provider Name (Legal Business Name) : KEITH WALTON FAODP
Provider Business Mailing Address
First Line : 91 GLENDALE ST
Second Line :
City : HIGHLAND PARK
State : MI
Zip : 48203-3274
Country : US
Telephone Number : 313-236-0077
Fax Number : 313-883-0442
Provider Business Practice Location Address
First Line : 91 GLENDALE ST
Second Line :
City : HIGHLAND PARK
State : MI
Zip : 48203-3274
Country : US
Telephone Number : 313-236-0077
Fax Number : 313-883-0442
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/09/2008
Last Update Date : 07/09/2008

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