Healthcare Provider Details

I. General information

NPI: 1497263487
Provider Name (Legal Business Name): EMMA MADISON LESTER WALLACE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 PEAK ONE DR SUITE 190
FRISCO CO
80443
US

IV. Provider business mailing address

360 PEAK ONE DR SUITE 190
FRISCO CO
80443
US

V. Phone/Fax

Practice location:
  • Phone: 970-668-0888
  • Fax: 970-668-0227
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0015349
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: