Provider Demographics
NPI:1518180595
Name:HAYLEY, WALTER EUGENE (LIC AC)
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:EUGENE
Last Name:HAYLEY
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26721 DUBLIN WOODS CIRCLE, #2
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135
Mailing Address - Country:US
Mailing Address - Phone:239-273-6788
Mailing Address - Fax:
Practice Address - Street 1:26721 DUBLIN WOODS CIRCLE, #2
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135
Practice Address - Country:US
Practice Address - Phone:239-273-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1023171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC0391OtherBLUE CROSS BLUE SHIELD