MEDICARE: JON T WALL D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2233-012	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053332650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON T WALL D.C.

Provider Business Mailing Address
First Line	:	18669 INNSWOOD RD
Second Line	:
City	:	NORWALK
State	:	WI
Zip	:	54648-7019
Country	:	US
Telephone Number	:	608-269-0585
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 PINE ST
Second Line	:
City	:	MAUSTON
State	:	WI
Zip	:	53948-1336
Country	:	US
Telephone Number	:	608-847-1888
Fax Number	:	608-847-1678

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	07/09/2007

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