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NPI Code Detail

MEDICARE: REBECCA HAGOOD WALLACE PT

MEDICARE: REBECCA HAGOOD WALLACE PT
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
1225100000XPhysical TherapistPT23837FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1710156765
Entity Type Code : Individual
Provider Name (Legal Business Name) : REBECCA HAGOOD WALLACE PT
Provider Business Mailing Address
First Line : 4119 SUMMERWOOD AVE
Second Line :
City : ORLANDO
State : FL
Zip : 32812-7944
Country : US
Telephone Number : 407-859-6122
Fax Number :
Provider Business Practice Location Address
First Line : 405 S SEMINOLE AVE
Second Line :
City : MINNEOLA
State : FL
Zip : 34715-5520
Country : US
Telephone Number : 352-394-0212
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/25/2008
Last Update Date : 02/25/2008

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