Provider Demographics
NPI:1538376108
Name:CHENEY, WALTER MAURIECE (CPO LPO)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:MAURIECE
Last Name:CHENEY
Suffix:
Gender:M
Credentials:CPO LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8630 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:TX
Mailing Address - Zip Code:79821-9275
Mailing Address - Country:US
Mailing Address - Phone:915-474-7216
Mailing Address - Fax:
Practice Address - Street 1:3901 MONTANA AVE STE C
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-4507
Practice Address - Country:US
Practice Address - Phone:915-566-3440
Practice Address - Fax:915-566-1485
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX161744P3200X
TX101161222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178724401Medicaid
TX16OtherTEXAS BOARD OF O&P
TX178724401Medicaid