Healthcare Provider Details

I. General information

NPI: 1457515587
Provider Name (Legal Business Name): STEVEN EARL WALLACE RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 BUCKS LAKE RD
QUINCY CA
95971-9507
US

IV. Provider business mailing address

2704 RIDGERUN RD
QUINCY CA
95971-9380
US

V. Phone/Fax

Practice location:
  • Phone: 530-283-7155
  • Fax: 530-283-1838
Mailing address:
  • Phone: 530-283-3504
  • Fax: 530-283-1838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZA2600X
TaxonomyMedical Art Specialist/Technologist
License Number243U00000X
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: