Individual
MR. JIM F WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
404 NE PENN AVE, BEND, OR 97701-4264
(541) 318-7041
(541) 388-3711
Mailing address
16693 GRAY WOLF LN, BEND, OR 97707-2548
(503) 956-8141
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
02948
OR
2251X0800X
Orthopedic Physical Therapist
2948
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500694596
—
OR
Enumeration date
06/06/2007
Last updated
12/29/2016
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