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General NPI Number Information
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NPI Number | 1720086838
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Entity Type | Organization
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Legal Business Name | ANTHONY WALLACE
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Dates
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Enumeration Date | 07/12/2005
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Last Update Date | 05/09/2018
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Provider Practice Location Address
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Address Line | 1414 PARK ST
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City | PASO ROBLES
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State | CA
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Zip | 93446-2160
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Country | US
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Telephone | 805-237-0272
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Fax | 805-237-2416
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Provider Business Mailing Address
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Address Line | 5255 EL CAMINO REAL STE C
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City | ATASCADERO
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State | CA
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Zip | 93422-3351
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Country | US
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Telephone | 805-237-0272
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Fax | 805-237-2416
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Authorized Official
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Title or Position | OWNER
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Name | MR. ANTHONY PAUL WALLACE
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Credential | PT
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Telephone | 805-237-0272
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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 10294
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License Number State | CA
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