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NPI Code Detail

MEDICARE: STEPHEN PADEN WALLACE PT, DPT

MEDICARE: STEPHEN PADEN WALLACE PT, DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical TherapistPT012936GA

General Provider Information

NPI Number : 1053849802
Entity Type Code : Individual
Provider Name (Legal Business Name) : STEPHEN PADEN WALLACE PT, DPT
Provider Business Mailing Address
First Line : 8823 PRODUCTION LN
Second Line :
City : OOLTEWAH
State : TN
Zip : 37363-6511
Country : US
Telephone Number : 423-238-7217
Fax Number : 423-362-8684
Provider Business Practice Location Address
First Line : 925 GARRETT ST SE STE J
Second Line :
City : ATLANTA
State : GA
Zip : 30316-6833
Country : US
Telephone Number : 404-624-5407
Fax Number : 404-624-5409
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/24/2017
Last Update Date : 09/25/2019

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