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NPI Code Detail

MEDICARE: BRUCE WALLACE

MEDICARE: BRUCE WALLACE
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
11041C0700XClinical Social WorkerLCSW-5142HI

General Provider Information

NPI Number : 1689341679
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRUCE WALLACE
Provider Business Mailing Address
First Line : 86-226 FARRINGTON HWY
Second Line :
City : WAIANAE
State : HI
Zip : 96792-3128
Country : US
Telephone Number : 808-696-9498
Fax Number :
Provider Business Practice Location Address
First Line : 85-888 FARRINGTON HWY
Second Line :
City : WAIANAE
State : HI
Zip : 96792-2403
Country : US
Telephone Number : 808-696-9498
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/26/2021
Last Update Date : 04/06/2026

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Directions to “ BRUCE WALLACE ” Practice Location

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