Healthcare Provider Details

I. General information

NPI: 1659760700
Provider Name (Legal Business Name): KEVIN WALLACE ND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 JUDITH LN
MODESTO CA
95350-4413
US

IV. Provider business mailing address

2842 N RICHEY BLVD
TUCSON AZ
85716-2023
US

V. Phone/Fax

Practice location:
  • Phone: 209-809-4251
  • Fax:
Mailing address:
  • Phone: 520-396-4866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number707
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: