MEDICARE: HYACINTH WALLACE P.T, 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
1	225100000X	Physical Therapist	PT31379	FL

General Provider Information

NPI Number	:	1396147047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HYACINTH WALLACE P.T, DPT

Provider Business Mailing Address
First Line	:	105 MARINER HEALTH WAY
Second Line	:	STE 213
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-3251
Country	:	US
Telephone Number	:	904-217-4259
Fax Number	:

Provider Business Practice Location Address
First Line	:	4008 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1807
Country	:	US
Telephone Number	:	773-481-0540
Fax Number	:

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

Provider Enumeration Date	:	09/24/2014
Last Update Date	:	06/14/2018

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