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General NPI Number Information
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NPI Number | 1679567192
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Entity Type | Individual
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Provider Name | LAWRENCE WALLACE MD, PT
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Gender | Male
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Dates
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Enumeration Date | 09/12/2005
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Last Update Date | 01/26/2026
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Provider Practice Location Address
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Address Line | 1021 2ND AVE N STE 6
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City | NORTH MYRTLE BEACH
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State | SC
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Zip | 29582-3200
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Country | US
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Telephone | 843-286-5168
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Fax | 844-318-8980
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Provider Business Mailing Address
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Address Line | 1021 2ND AVE N STE 6
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City | NORTH MYRTLE BEACH
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State | SC
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Zip | 29582-3200
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Country | US
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Telephone | 843-286-5168
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Fax | 844-318-8980
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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 | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | MD439714
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | P2177
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 0101234728
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License Number State | VA
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Taxonomy #4
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 11194
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License Number State | SC
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