MEDICARE: JOHN WALLACE SR. IDC

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
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1316926066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WALLACE SR. IDC

Provider Business Mailing Address
First Line	:	235 JONATHANS WAY
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23434-9153
Country	:	US
Telephone Number	:	757-923-3793
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 E MAIN ST
Second Line	:	SUITE 1000
City	:	NORFOLK
State	:	VA
Zip	:	23510-1753
Country	:	US
Telephone Number	:	757-628-4347
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	07/08/2007

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