Provider Demographics
NPI:1023720182
Name:LEWALLEN, DALTON RUSSELL (DC)
Entity type:Individual
Prefix:DR
First Name:DALTON
Middle Name:RUSSELL
Last Name:LEWALLEN
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:W8894 BROKEN ARROW RD
Mailing Address - Street 2:
Mailing Address - City:CONRATH
Mailing Address - State:WI
Mailing Address - Zip Code:54731-9783
Mailing Address - Country:US
Mailing Address - Phone:715-206-0073
Mailing Address - Fax:
Practice Address - Street 1:500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CADOTT
Practice Address - State:WI
Practice Address - Zip Code:54727-9401
Practice Address - Country:US
Practice Address - Phone:715-289-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6041-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor