Healthcare Provider Details

I. General information

NPI: 1821366550
Provider Name (Legal Business Name): MARK V. WALTERS DC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
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

VIII. Authorized Official

Name: DR. MARK V WALTERS
Title or Position: OWNER/OPERATOR
Credential: D.C
Phone: 417-461-1155