Healthcare Provider Details

I. General information

NPI: 1467888537
Provider Name (Legal Business Name): DONALD W WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 PERSHING CT STE 101
DECATUR IL
62526-6323
US

IV. Provider business mailing address

3113 FLINTLOCK PATH
SAINT CHARLES MO
63301-3902
US

V. Phone/Fax

Practice location:
  • Phone: 217-330-9654
  • Fax:
Mailing address:
  • Phone: 314-761-7510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2013004501
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: