Individual
GARY ROBERT WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
13 NORTHTOWN DR, TRINITY REHAB SUITE 110, JACKSON, MS 39211
(601) 206-9195
(601) 957-8391
Mailing address
13 NORTHTOWN DR, SUITE 110 TRINITY REHAB, JACKSON, MS 39211
(601) 206-9195
(601) 957-8391
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
A2636
LA
Other
Enumeration date
08/22/2007
Last updated
08/22/2007
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