Healthcare Provider Details

I. General information

NPI: 1902802457
Provider Name (Legal Business Name): GREGORY L WALTER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

5219 PETERS CREEK RD NW SUITE 5
ROANOKE VA
24019-3864
US

IV. Provider business mailing address

8521 BARRENS RD
ROANOKE VA
24019-6705
US

V. Phone/Fax

Practice location:
  • Phone: 540-362-0811
  • Fax: 540-362-5025
Mailing address:
  • Phone: 540-563-0487
  • Fax: 540-362-5025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104000425
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: