Provider Demographics
NPI:1447302922
Name:WALDEN CHIROPRACTIC PSC
Entity type:Organization
Organization Name:WALDEN CHIROPRACTIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-585-5400
Mailing Address - Street 1:1072 BARDSTOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204
Mailing Address - Country:US
Mailing Address - Phone:502-585-5400
Mailing Address - Fax:502-585-9592
Practice Address - Street 1:1072 BARDSTOWN ROAD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204
Practice Address - Country:US
Practice Address - Phone:502-585-5400
Practice Address - Fax:502-585-9592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4412111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85000743Medicaid
KY50010510Medicaid
KY000000390322OtherANTHEM
KYT86708Medicare UPIN
KY85000743Medicaid