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General NPI Number Information
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NPI Number | 1205289139
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Entity Type | Individual
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Provider Name | CHARLES DUANE WALTHALL PTA
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Gender | Male
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Dates
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Enumeration Date | 07/15/2016
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Last Update Date | 07/15/2016
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Provider Practice Location Address
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Address Line | 5353 E YALE AVE
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City | DENVER
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State | CO
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Zip | 80222-6902
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Country | US
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Telephone | 303-757-1209
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Fax |
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Provider Business Mailing Address
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Address Line | 6116 W ARIZONA AVE
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City | LAKEWOOD
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State | CO
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Zip | 80232-5709
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Country | US
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Telephone | 720-938-5907
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 13894
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License Number State | CO
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