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General NPI Number Information
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NPI Number | 1679529010
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Entity Type | Organization
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Legal Business Name | WALNUT LANE MANAGEMENT LLC
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Dates
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Enumeration Date | 05/26/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 148 WALNUT LANE SUITE I
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City | TRAVELERS REST
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State | SC
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Zip | 29690
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Country | US
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Telephone | 864-834-8099
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Fax | 864-834-8108
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Provider Business Mailing Address
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Address Line | PO BOX 1111
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City | TRAVELERS REST
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State | SC
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Zip | 29690
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Country | US
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Telephone | 864-834-8099
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Fax | 864-834-8108
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | MRS. NANCY WYLIE ST JOHN
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Credential | DC
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Telephone | 864-834-8099
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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 | 1637
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License Number State | SC
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