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General NPI Number Information
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NPI Number | 1962947960
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Entity Type | Organization
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Legal Business Name | ELYSSA N WALLER
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Dates
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Enumeration Date | 12/29/2016
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Last Update Date | 12/29/2016
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Provider Practice Location Address
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Address Line | 4729 HIGHWAY 90
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City | MARIANNA
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State | FL
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Zip | 32446-6820
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Country | US
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Telephone | 850-482-2373
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Fax | 850-482-2395
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Provider Business Mailing Address
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Address Line | 4729 HIGHWAY 90
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City | MARIANNA
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State | FL
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Zip | 32446-6820
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Country | US
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Telephone | 850-482-2373
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Fax | 850-482-2395
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Authorized Official
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Title or Position | OWNER
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Name | DR. ELYSSA WALLER
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Credential | DC
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Telephone | 850-482-2373
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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 | CH9060
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License Number State | FL
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