Healthcare Provider Details

I. General information

NPI: 1760828974
Provider Name (Legal Business Name): MARY EARALYN WALKER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

127 TOWNE SQUARE RD
SUMMERVILLE SC
29485-5248
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-6131
  • Fax: 843-805-5973
Mailing address:
  • Phone: 843-478-1471
  • Fax: 840-805-5973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number429
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: