Healthcare Provider Details

I. General information

NPI: 1548916125
Provider Name (Legal Business Name): SAVANNAH WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 EDWARDS LAKE RD STE 114
BIRMINGHAM AL
35235-3719
US

IV. Provider business mailing address

204 WOODHEW DR
WACO TX
76712-6529
US

V. Phone/Fax

Practice location:
  • Phone: 205-267-6110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2332
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: