Healthcare Provider Details

I. General information

NPI: 1932779055
Provider Name (Legal Business Name): STEWART MIMS WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HACKBERRY LN
DURHAM NC
27705-7947
US

IV. Provider business mailing address

1000 HACKBERRY LN
DURHAM NC
27705-7947
US

V. Phone/Fax

Practice location:
  • Phone: 919-489-5355
  • Fax:
Mailing address:
  • Phone: 919-490-1815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1286
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: