Basic Information
| Provider Information | |||||||||
| NPI: | 1154655231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BA, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 MARLIN LN | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377165982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8658987448 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2702 FARRELL RD | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273306505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197769602 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2009 | ||||||||
| LastUpdateDate: | 09/23/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12280 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.