Healthcare Provider Details

I. General information

NPI: 1285794990
Provider Name (Legal Business Name): MARK VINCENT WALTERS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 W MOUNT VERNON BLVD
MOUNT VERNON MO
65712-1940
US

IV. Provider business mailing address

316 W MOUNT VERNON BLVD
MOUNT VERNON MO
65712-1940
US

V. Phone/Fax

Practice location:
  • Phone: 417-461-1155
  • Fax: 417-461-1155
Mailing address:
  • Phone: 417-461-1155
  • Fax: 417-461-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number006467
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number006467
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: