Basic Information
Provider Information | |||||||||
NPI: | 1437555083 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WALKO ENTERPRISE INCORPORATED | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1788 REPUBLIC RD | ||||||||
Address2: |   | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 23454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7576408673 | ||||||||
FaxNumber: | 7574374582 | ||||||||
Practice Location | |||||||||
Address1: | 1788 REPUBLIC RD | ||||||||
Address2: |   | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 23454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7576408673 | ||||||||
FaxNumber: | 7574374582 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2014 | ||||||||
LastUpdateDate: | 02/13/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALKO | ||||||||
AuthorizedOfficialFirstName: | EDWARD | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7576408673 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 0102049902 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.