MEDICARE: WALLACE R RYNE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	02485TG	TX

General Provider Information

NPI Number	:	1164421319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALLACE R RYNE O.D.

Provider Business Mailing Address
First Line	:	6452 ALEXANDRA MEADOWS DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76131-1221
Country	:	US
Telephone Number	:	817-232-3203
Fax Number	:

Provider Business Practice Location Address
First Line	:	1980 E NORTHWEST PKWY
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-6510
Country	:	US
Telephone Number	:	817-329-2700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	03/07/2023

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