MEDICARE: ZACHARY E WALSTON DPT

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	225100000X	Physical Therapist	PT011588	GA

General Provider Information

NPI Number	:	1922400704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHARY E WALSTON DPT

Provider Business Mailing Address
First Line	:	PO BOX 242278
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36124-2278
Country	:	US
Telephone Number	:	334-396-3273
Fax Number	:	334-396-4905

Provider Business Practice Location Address
First Line	:	4849 S COBB DR SE
Second Line	:	SUITE 121
City	:	SMYRNA
State	:	GA
Zip	:	30080-7145
Country	:	US
Telephone Number	:	866-464-3878
Fax Number	:	334-396-4905

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

Provider Enumeration Date	:	09/23/2014
Last Update Date	:	09/23/2014

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