Provider Demographics
NPI:1972694396
Name:WALL, JOHN CHARLES BLAKELY (DC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CHARLES BLAKELY
Last Name:WALL
Suffix:
Gender:M
Credentials:DC
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Mailing Address - Street 1:1334 MACKEY BRANCH DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3471
Mailing Address - Country:US
Mailing Address - Phone:423-296-2604
Mailing Address - Fax:423-296-2607
Practice Address - Street 1:1334 MACKEY BRANCH DR
Practice Address - Street 2:SUITE 104
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3471
Practice Address - Country:US
Practice Address - Phone:423-296-2604
Practice Address - Fax:423-296-2607
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2016-05-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GACHIR005485111N00000X
TNDC0000001504111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGWPMedicare PIN
GAU78769Medicare UPIN