Healthcare Provider Details

I. General information

NPI: 1447462270
Provider Name (Legal Business Name): RACHEL L WALLACE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MEDICAL DR
LIMA OH
45804-4099
US

IV. Provider business mailing address

2950 N THAYER RD
LIMA OH
45801-9770
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-6622
  • Fax: 419-222-4069
Mailing address:
  • Phone: 419-224-7660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000841
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: