Healthcare Provider Details

I. General information

NPI: 1710003157
Provider Name (Legal Business Name): JOSEPH BRUCE WALTERS M.S. P.T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 W CENTRE AVE
PORTAGE MI
49024-5351
US

IV. Provider business mailing address

5581 BOBWHITE AVE
KALAMAZOO MI
49009-4593
US

V. Phone/Fax

Practice location:
  • Phone: 269-323-4300
  • Fax: 269-323-4449
Mailing address:
  • Phone: 269-375-3404
  • Fax: 269-323-4300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5501008230
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: