Provider Demographics
NPI:1285240523
Name:BALL, BURLEY WALTER JR
Entity type:Individual
Prefix:MR
First Name:BURLEY
Middle Name:WALTER
Last Name:BALL
Suffix:JR
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:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:COEBURN
Mailing Address - State:VA
Mailing Address - Zip Code:24230-0208
Mailing Address - Country:US
Mailing Address - Phone:276-395-1323
Mailing Address - Fax:
Practice Address - Street 1:4313 BUCKINGHAM RD
Practice Address - Street 2:
Practice Address - City:COEBURN
Practice Address - State:VA
Practice Address - Zip Code:24230
Practice Address - Country:US
Practice Address - Phone:276-395-1323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT64011149172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT64011149Medicaid