Provider Demographics
NPI:1902505118
Name:WALZ, JOHNATHAN RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:RICHARD
Last Name:WALZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 YELLOW BRICK RD APT 104
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2171
Mailing Address - Country:US
Mailing Address - Phone:651-470-7289
Mailing Address - Fax:
Practice Address - Street 1:23505 SMITHTOWN RD STE 100
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-4542
Practice Address - Country:US
Practice Address - Phone:952-470-8555
Practice Address - Fax:952-401-8785
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7087111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor