Provider Demographics
NPI:1063615243
Name:WALLIS, ROGER D (PC)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
Last Name:WALLIS
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1823
Mailing Address - Country:US
Mailing Address - Phone:303-857-6344
Mailing Address - Fax:
Practice Address - Street 1:419 DENVER AVE
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1823
Practice Address - Country:US
Practice Address - Phone:303-857-6344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1509111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC491948Medicare PIN