Healthcare Provider Details

I. General information

NPI: 1831150705
Provider Name (Legal Business Name): BETSY A WALLACE PT OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 03/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 CAMINO DEL RIO S STE 100A
SAN DIEGO CA
92108-4031
US

IV. Provider business mailing address

600 S ANDREASEN DR STE C
ESCONDIDO CA
92029-1917
US

V. Phone/Fax

Practice location:
  • Phone: 619-269-2336
  • Fax: 619-269-7608
Mailing address:
  • Phone: 760-591-7750
  • Fax: 760-294-9813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT16506
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: