MEDICARE: MR. BRIAN LESLIE WALLACE PT, DPT, OCS

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	2251X0800X	Orthopedic Physical Therapist	10128	NC
2	225100000X	Physical Therapist	10128	NC

General Provider Information

NPI Number	:	1790888501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN LESLIE WALLACE PT, DPT, OCS

Provider Business Mailing Address
First Line	:	2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-0001
Country	:	US
Telephone Number	:	910-807-8922
Fax Number	:

Provider Business Practice Location Address
First Line	:	2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-6920
Country	:	US
Telephone Number	:	910-807-8922
Fax Number	:

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

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	06/18/2025

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