Basic Information
| Provider Information | |||||||||
| NPI: | 1003478553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | REED | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1604 VISA DR. | ||||||||
| Address2: | STE. 1 | ||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098464716 | ||||||||
| FaxNumber: | 3094547348 | ||||||||
| Practice Location | |||||||||
| Address1: | 1604 VISA DR. | ||||||||
| Address2: | STE. 1 | ||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098464716 | ||||||||
| FaxNumber: | 3094547348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2019 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246Z00000X | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |
No ID Information.