Healthcare Provider Details

I. General information

NPI: 1003009184
Provider Name (Legal Business Name): GARY ROBERT WALLACE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 NORTHTOWN DR TRINITY REHAB SUITE 110
JACKSON MS
39211
US

IV. Provider business mailing address

13 NORTHTOWN DR SUITE 110 TRINITY REHAB
JACKSON MS
39211
US

V. Phone/Fax

Practice location:
  • Phone: 601-206-9195
  • Fax: 601-957-8391
Mailing address:
  • Phone: 601-206-9195
  • Fax: 601-957-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA2636
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: