Basic Information
| Provider Information | |||||||||
| NPI: | 1710069828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | O'NEIL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012273255 | ||||||||
| FaxNumber: | 9012273205 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 CLINTON PKWY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390564730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019262018 | ||||||||
| FaxNumber: | 6019249746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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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 | 225100000X | PT3649 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 08855377 | 05 | MS | MEDICAID |