Healthcare Provider Details

I. General information

NPI: 1255972568
Provider Name (Legal Business Name): ROBERT BOWMAN WALLACE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5935 CARNEGIE BLVD STE 104
CHARLOTTE NC
28209-4672
US

IV. Provider business mailing address

PO BOX 601791
CHARLOTTE NC
28260-1791
US

V. Phone/Fax

Practice location:
  • Phone: 43-232-5007
  • Fax: 704-323-3993
Mailing address:
  • Phone: 704-323-3611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP19188
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: