=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497295117
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELETHA WALKER MMP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2017
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 WALKER SMITH RD
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-954-6831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 WALKER SMITH RD
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39073-8444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 1569
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------