Provider Demographics
NPI:1932082070
Name:WALLER, THELBERT JUWON
Entity type:Individual
Prefix:
First Name:THELBERT
Middle Name:JUWON
Last Name:WALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2725
Mailing Address - Country:US
Mailing Address - Phone:434-710-6788
Mailing Address - Fax:
Practice Address - Street 1:2124 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2725
Practice Address - Country:US
Practice Address - Phone:434-710-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-28
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60714893343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)