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General NPI Number Information
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NPI Number | 1790872109
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Entity Type | Organization
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Legal Business Name | WALKER SPINE AND SPORTS SPECIALISTS
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 03/10/2016
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Provider Practice Location Address
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Address Line | 2319 CORONADO ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7407
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Country | US
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Telephone | 208-227-1200
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Fax | 208-227-1212
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Provider Business Mailing Address
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Address Line | 2319 CORONADO ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7407
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Country | US
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Telephone | 208-227-1200
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Fax | 208-227-1212
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Authorized Official
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Title or Position | OWNER
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Name | GARY C WALKER
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Credential | MD
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Telephone | 208-227-1200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204C00000X
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Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
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License Number | E65389
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License Number State | ID
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