Basic Information
Provider Information
NPI: 1649766924
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WALTERS
FirstName: MACEY
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2526 51ST ST
Address2:  
City: SACRAMENTO
State: CA
PostalCode: 958171616
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 6000 J STREET
Address2:  
City: SACRAMENTO
State: CA
PostalCode: 958196073
CountryCode: US
TelephoneNumber: 9165482562
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/10/2018
LastUpdateDate: 07/10/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000XRBT-17-46885CAY    

No ID Information.


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