Basic Information
| Provider Information | |||||||||
| NPI: | 1225233091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 EISENHOWER DR | ||||||||
| Address2: | CR2 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617012060 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | WILLOWBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605275603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304556630 | ||||||||
| FaxNumber: | 6304556631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2255A2300X | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.