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Individual

MR. BRUCE J. WALLENTINE

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
MPT

Contact information

Practice address
900 LANARK RD, OVID, ID 83254-4934
(208) 945-2900
(208) 945-2900
Mailing address
900 LANARK RD, OVID, ID 83254-4934
(208) 945-2900
(208) 945-2900

Taxonomy

Speciality
Code
Description
License number
State
225100000X
Physical Therapist
362968-2401
UT
225100000X
Physical Therapist
PT-389
WY
225100000X
Physical Therapist
Primary
PT-593
ID

Other

Enumeration date
08/31/2006
Last updated
07/08/2007
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