Healthcare Provider Details

I. General information

NPI: 1376470591
Provider Name (Legal Business Name): JAMES WALLACE BA DEGREE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 S SAN JACINTO AVE
SAN JACINTO CA
92583-5626
US

IV. Provider business mailing address

28437 HEATHER GREEN WAY
MENIFEE CA
92584-1600
US

V. Phone/Fax

Practice location:
  • Phone: 951-929-7700
  • Fax:
Mailing address:
  • Phone: 760-390-5557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: