MEDICARE: RYAN JAMES WALLACE PT, DPT, OCS, MTC

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	PT 18604	FL

General Provider Information

NPI Number	:	1568420354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN JAMES WALLACE PT, DPT, OCS, MTC

Provider Business Mailing Address
First Line	:	8079 BRETON CIR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4651
Country	:	US
Telephone Number	:	239-947-4184
Fax Number	:	239-947-4181

Provider Business Practice Location Address
First Line	:	25241 ELEMENTARY WAY
Second Line	:	STE 200
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-7883
Country	:	US
Telephone Number	:	239-947-4184
Fax Number	:	239-947-4171

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

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	05/12/2015

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