MEDICARE: DR. KENNETH C WALLIS M.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	2084P0800X	Psychiatry Physician	C-41960	CA
2	2084P0800X	Psychiatry Physician	811674181205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	107005564101	OTHER	UT	INTRMTN. HEALTH CARE
2	261795	OTHER	UT	DESERET MUTUAL
3	942938348WA1	OTHER	UT	EDUCATORS MUTUAL

General Provider Information

NPI Number	:	1649243692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH C WALLIS M.D.

Provider Business Mailing Address
First Line	:	1260 LAKE BLVD
Second Line	:	SUITE #214
City	:	DAVIS
State	:	CA
Zip	:	95616-2614
Country	:	US
Telephone Number	:	530-771-2308
Fax Number	:	530-771-2309

Provider Business Practice Location Address
First Line	:	1260 LAKE BLVD
Second Line	:	SUITE #214
City	:	DAVIS
State	:	CA
Zip	:	95616-2614
Country	:	US
Telephone Number	:	530-771-2308
Fax Number	:	530-771-2309

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

Provider Enumeration Date	:	02/09/2006
Last Update Date	:	07/09/2021

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