=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336175918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALCOTT CHIROPRACTIC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 01/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14260 BUSTLETON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19116-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-676-0104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1548 REVERE RD
-----------------------------------------------------
City | YARDLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19067-4351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-493-1590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHRISTOPHER VAILL WALCOTT
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 215-493-1590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC007908L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------