Provider Demographics
NPI:1285455600
Name:WALLER, CLIFTON
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CLIFF
Other - Middle Name:
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:90 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-2301
Mailing Address - Country:US
Mailing Address - Phone:740-773-4366
Mailing Address - Fax:
Practice Address - Street 1:666 BUCKEYE ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-1244
Practice Address - Country:US
Practice Address - Phone:740-773-4366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator