Basic Information
| Provider Information | |||||||||
| NPI: | 1578839981 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | BRADLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8800 SE SUNNYSIDE RD | ||||||||
| Address2: | STE. 300-N | ||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036595115 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6175 CAHILL AVE | ||||||||
| Address2: | STE. 103 | ||||||||
| City: | INVER GROVE HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550765501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519677753 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.