Basic Information
| Provider Information | |||||||||
| NPI: | 1588738611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | WAIDE | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | BS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 WEST SPRUCE | ||||||||
| Address2: | |||||||||
| City: | PORTALES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053568175 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 121 TOWNSGATE PLZ | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 881013714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757422620 | ||||||||
| FaxNumber: | 5757423182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.