Provider Demographics
NPI:1891933834
Name:STREET, WALTER D (CONTRACTOR)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:D
Last Name:STREET
Suffix:
Gender:M
Credentials:CONTRACTOR
Other - Prefix:MR
Other - First Name:WALTER
Other - Middle Name:D
Other - Last Name:STREET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:WALTER STREET CONSTR
Mailing Address - Street 1:573 MOUNT HERMON CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:BASSETT
Mailing Address - State:VA
Mailing Address - Zip Code:24055-3569
Mailing Address - Country:US
Mailing Address - Phone:276-618-0174
Mailing Address - Fax:
Practice Address - Street 1:573 MOUNT HERMON CHURCH RD
Practice Address - Street 2:
Practice Address - City:BASSETT
Practice Address - State:VA
Practice Address - Zip Code:24055-3569
Practice Address - Country:US
Practice Address - Phone:276-618-0174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2701036899A171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor