Basic Information
| Provider Information | |||||||||
| NPI: | 1215539978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | WILLIAM | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 ROUTE 9 N STE 410 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070951003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018017141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2630 E CHESTNUT AVE STE C5 | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083618400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566921483 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2020 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 40QB00349400 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.