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NPI Code Detail

MEDICARE: WILLIAM C WALLACE PT

MEDICARE: WILLIAM C WALLACE PT
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 TherapistPT 4793TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14793OTHERTNPT LICENSE

General Provider Information

NPI Number : 1508880493
Entity Type Code : Individual
Provider Name (Legal Business Name) : WILLIAM C WALLACE PT
Provider Business Mailing Address
First Line : 1113 N CASTLE HEIGHTS AVE
Second Line : SUITE D
City : LEBANON
State : TN
Zip : 37087-5640
Country : US
Telephone Number : 615-965-9000
Fax Number : 615-965-9001
Provider Business Practice Location Address
First Line : 1113 N CASTLE HEIGHTS AVE
Second Line : SUITE D
City : LEBANON
State : TN
Zip : 37087-5640
Country : US
Telephone Number : 615-965-9000
Fax Number : 615-965-9001
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/26/2006
Last Update Date : 06/07/2013

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