=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750449971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM L WALLS BOCO, CPED, CO,OPA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 OSIGIAN BLVD
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31088-7880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-953-2922
-----------------------------------------------------
Fax | 478-953-2927
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 COMMERCE ST W
-----------------------------------------------------
City | PINEVIEW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31071-3145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-624-2723
-----------------------------------------------------
Fax | 478-953-2927
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 000009
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------