Provider Demographics
NPI:1447810700
Name:WALKER, TOMMY OTIS (BA)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:OTIS
Last Name:WALKER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-3941
Mailing Address - Country:US
Mailing Address - Phone:323-632-1710
Mailing Address - Fax:
Practice Address - Street 1:11565 LAUREL CANYON BLVD STE 218
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4652
Practice Address - Country:US
Practice Address - Phone:818-901-8985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner