MEDICARE: ERIC DOUGLAS WALLER PTA

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	225200000X	Physical Therapy Assistant	5502000667	MI

General Provider Information

NPI Number	:	1134841042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC DOUGLAS WALLER PTA

Provider Business Mailing Address
First Line	:	7603 8TH ST
Second Line	:
City	:	STANWOOD
State	:	MI
Zip	:	49346-9664
Country	:	US
Telephone Number	:	989-488-0213
Fax Number	:

Provider Business Practice Location Address
First Line	:	1620 S MISSION ST STE O
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-4466
Country	:	US
Telephone Number	:	989-282-0320
Fax Number	:

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

Provider Enumeration Date	:	09/16/2022
Last Update Date	:	09/16/2022

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