Provider Demographics
NPI:1548525934
Name:WALLACE, MARIE L (CPC PERMIT #IP150410)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CPC PERMIT #IP150410
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10327 BIRCH BLUFF LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145
Mailing Address - Country:US
Mailing Address - Phone:702-304-1551
Mailing Address - Fax:702-304-1551
Practice Address - Street 1:3606 NORTH RONCHO DR
Practice Address - Street 2:SUITE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130
Practice Address - Country:US
Practice Address - Phone:504-400-5768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty