Individual
KEVIN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
100 BIBLE CROSSING RD, DECHARD, TN 37324
(931) 962-9947
Mailing address
651 WILLIAMS ST, DECHERD, TN 37324-3906
(931) 691-9262
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
0000000293
TN
Other
Enumeration date
09/03/2021
Last updated
09/03/2021
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