=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659760700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN WALLACE ND
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2015
-----------------------------------------------------
Last Update Date | 02/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 JUDITH LN
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-4413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-809-4251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2842 N RICHEY BLVD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85716-2023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-396-4866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 707
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------