Provider Demographics
NPI:1528423308
Name:WALTENBERGER, BOSTON (LAT, ATC)
Entity type:Individual
Prefix:
First Name:BOSTON
Middle Name:
Last Name:WALTENBERGER
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-5549
Mailing Address - Country:US
Mailing Address - Phone:919-228-4682
Mailing Address - Fax:919-677-8761
Practice Address - Street 1:1500 N HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-5549
Practice Address - Country:US
Practice Address - Phone:919-228-4682
Practice Address - Fax:919-677-8761
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-25122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer