Healthcare Provider Details

I. General information

NPI: 1477151132
Provider Name (Legal Business Name): WALNER CIUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 SW MCALLISTER LN
PORT ST LUCIE FL
34953-2064
US

IV. Provider business mailing address

970 SE BAYFRONT AVE
PORT ST LUCIE FL
34983-3912
US

V. Phone/Fax

Practice location:
  • Phone: 561-502-2744
  • Fax:
Mailing address:
  • Phone: 561-502-2744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: