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General NPI Number Information
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NPI Number | 1164421319
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Entity Type | Individual
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Provider Name | WALLACE R RYNE O.D.
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Gender | Male
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Dates
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Enumeration Date | 07/19/2005
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1980 E NORTHWEST PKWY
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6510
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Country | US
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Telephone | 817-329-2700
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Fax |
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Provider Business Mailing Address
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Address Line | 6452 ALEXANDRA MEADOWS DR
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City | FORT WORTH
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State | TX
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Zip | 76131-1221
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Country | US
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Telephone | 817-232-3203
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 02485TG
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License Number State | TX
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