Healthcare Provider Details

I. General information

NPI: 1245712819
Provider Name (Legal Business Name): CLINTIN SPENCER WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N MEDFORD DR
LUFKIN TX
75901-5219
US

IV. Provider business mailing address

11978 COUNTY ROAD 302
NACOGDOCHES TX
75961-7687
US

V. Phone/Fax

Practice location:
  • Phone: 936-639-1252
  • Fax:
Mailing address:
  • Phone: 318-235-2887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: