Provider Demographics
NPI:1861423394
Name:WALLACE PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:WALLACE PHYSICAL THERAPY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCHAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-278-5202
Mailing Address - Street 1:250 S VOZACK LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748-4539
Mailing Address - Country:US
Mailing Address - Phone:520-278-5202
Mailing Address - Fax:800-392-0662
Practice Address - Street 1:250 S VOZACK LN STE C
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85748-4539
Practice Address - Country:US
Practice Address - Phone:202-785-2025
Practice Address - Fax:800-392-0662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS45679Medicare UPIN
AZZ68619Medicare PIN