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General NPI Number Information
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NPI Number | 1083894489
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Entity Type | Organization
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Legal Business Name | ROGER D WALLIS DCPC
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Dates
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Enumeration Date | 11/14/2007
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Last Update Date | 07/26/2012
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Provider Practice Location Address
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Address Line | 419 DENVER AVE
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City | FORT LUPTON
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State | CO
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Zip | 80621-1823
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Country | US
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Telephone | 303-857-6344
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Fax | 303-857-6250
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Provider Business Mailing Address
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Address Line | 419 DENVER AVE
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City | FORT LUPTON
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State | CO
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Zip | 80621-1823
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Country | US
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Telephone | 303-857-6344
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Fax | 303-857-6250
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROGER DALE WALLIS
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Credential | P.C.
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Telephone | 303-857-6344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 1509
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License Number State | CO
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