=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689760084
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CODY RAY WALTER D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 09/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 1/2 LOCUST ST SUITE B
-----------------------------------------------------
City | BLAIRSTOWN
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-454-6455
-----------------------------------------------------
Fax | 319-454-0091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 267
-----------------------------------------------------
City | BLAIRSTOWN
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52209-0267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-454-6455
-----------------------------------------------------
Fax | 319-454-0091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 06430
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------