| Doctor Name: | MR. THOMAS WALLER |
| NPI Number: | 1518113067 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | W46082583086 |
| Business Practice Address: | 430 E 162nd St Suite 522 South Holland, IL - 604732258 |
| Business Phone Number: | 7738953921 |
| Business Fax Number: | 7085750432 |
| Mailing Address: | 430 E 162nd St, Suite 522 SOUTH HOLLAND |
| State: | IL |
| Postal Code: | 604732258 |
| Phone Number: | 7738953921 |
| Fax Number: | 7085750432 |
| NPI Enumeration Date: | 08/15/2008 |
| NPI Last Update Date: | 08/15/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 172A00000X |
| License Number: | W46082583086 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Driver |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A person employed to operate a motor vehicle as a carrier of persons or property. |