Healthcare Provider Details

I. General information

NPI: 1699096909
Provider Name (Legal Business Name): JOHN WALTER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 GIBSON DR # 1821
ROSEVILLE CA
95678-5400
US

IV. Provider business mailing address

301 GIBSON DR # 1821
ROSEVILLE CA
95678-5400
US

V. Phone/Fax

Practice location:
  • Phone: 707-372-2649
  • Fax:
Mailing address:
  • Phone: 707-372-2649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number15618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: