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General NPI Number Information
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NPI Number | 1619696648
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Entity Type | Individual
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Provider Name | JONATHAN WALLACE DPT
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Gender | Male
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Dates
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Enumeration Date | 08/23/2022
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Last Update Date | 08/23/2022
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Provider Practice Location Address
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Address Line | 8040 PETERS RD STE H107
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City | PLANTATION
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State | FL
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Zip | 33324-4029
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Country | US
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Telephone | 954-835-5619
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Fax |
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Provider Business Mailing Address
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Address Line | 3828 NW 107TH WAY
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City | SUNRISE
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State | FL
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Zip | 33351-8108
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Country | US
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Telephone | 954-612-6315
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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