Individual
BRIAN VENSON WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPT
Contact information
Practice address
711 AVIGNON DR, RIDGELAND, MS 39157-5120
(601) 605-6777
(601) 607-1553
Mailing address
711 AVIGNON DR, RIDGELAND, MS 39157-5120
(601) 605-6777
(601) 607-1553
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT 4550
MS
Other
Enumeration date
07/25/2012
Last updated
07/25/2012
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