Healthcare Provider Details

I. General information

NPI: 1902294200
Provider Name (Legal Business Name): MEGAN WALLER ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E FRANKLIN ST
HILLSBORO TX
76645-2137
US

IV. Provider business mailing address

401 E JACINTO ST
GROESBECK TX
76642-1523
US

V. Phone/Fax

Practice location:
  • Phone: 254-747-0780
  • Fax:
Mailing address:
  • Phone: 254-747-0780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT5880
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: