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General NPI Number Information
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NPI Number | 1568420354
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Entity Type | Individual
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Provider Name | RYAN JAMES WALLACE PT, DPT, OCS, MTC
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Gender | Male
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Dates
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Enumeration Date | 05/02/2006
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Last Update Date | 05/12/2015
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Provider Practice Location Address
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Address Line | 25241 ELEMENTARY WAY STE 200
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City | BONITA SPRINGS
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State | FL
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Zip | 34135-7883
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Country | US
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Telephone | 239-947-4184
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Fax | 239-947-4171
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Provider Business Mailing Address
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Address Line | 8079 BRETON CIR
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City | FORT MYERS
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State | FL
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Zip | 33912-4651
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Country | US
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Telephone | 239-947-4184
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Fax | 239-947-4181
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT 18604
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License Number State | FL
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