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General NPI Number Information
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NPI Number | 1114220738
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Entity Type | Organization
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Legal Business Name | AUGUST M WALLACE ENTERPRISES, LLC
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Dates
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Enumeration Date | 12/21/2010
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Last Update Date | 12/21/2010
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Provider Practice Location Address
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Address Line | 805 HIGHWAY 9 BYP W
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City | LANCASTER
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State | SC
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Zip | 29720
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Country | US
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Telephone | 803-286-4836
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Fax |
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Provider Business Mailing Address
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Address Line | 805 HIGHWAY 9 BYP W
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City | LANCASTER
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State | SC
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Zip | 29720
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Country | US
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Telephone | 803-286-4836
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. AUGUST M WALLACE
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Credential | OD
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Telephone | 803-201-8526
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1483
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License Number State | SC
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