Healthcare Provider Details

I. General information

NPI: 1790872109
Provider Name (Legal Business Name): WALKER SPINE AND SPORTS SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 CORONADO ST
IDAHO FALLS ID
83404-7407
US

IV. Provider business mailing address

2319 CORONADO ST
IDAHO FALLS ID
83404-7407
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-1200
  • Fax: 208-227-1212
Mailing address:
  • Phone: 208-227-1200
  • Fax: 208-227-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberE65389
License Number StateID

VIII. Authorized Official

Name: GARY C WALKER
Title or Position: OWNER
Credential: MD
Phone: 208-227-1200