Healthcare Provider Details

I. General information

NPI: 1457444580
Provider Name (Legal Business Name): WALLACE L PHILLIPS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S EAST AVE
KERMIT TX
79745-3606
US

IV. Provider business mailing address

103 S EAST AVE
KERMIT TX
79745-3606
US

V. Phone/Fax

Practice location:
  • Phone: 432-586-3435
  • Fax: 432-586-6737
Mailing address:
  • Phone: 432-586-3435
  • Fax: 432-586-6737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2869TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: