MEDICARE: MR. JAMES LEWIS WALLACE JR. CPO

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	222Z00000X	Orthotist
2	224P00000X	Prosthetist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396891933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES LEWIS WALLACE JR. CPO

Provider Business Mailing Address
First Line	:	PO BOX 24905
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27114-4905
Country	:	US
Telephone Number	:	336-397-2165
Fax Number	:	336-397-2167

Provider Business Practice Location Address
First Line	:	1901 BRUNSWICK AVE
Second Line	:	SUITE 200
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-2809
Country	:	US
Telephone Number	:	704-348-4488
Fax Number	:	704-348-4496

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

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	07/23/2010

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