Individual
TINA MARIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1363 VETERANS MEMORIAL HWY STE 8, HAUPPAUGE, NY 11788-3046
(631) 366-3876
Mailing address
124 SOUTH PATH, CALVERTON, NY 11933-1135
(631) 831-6676
Taxonomy
Speciality
Code
Description
License number
State
152WV0400X
Vision Therapy Optometrist
Primary
82685981
NY
Other
Enumeration date
12/09/2019
Last updated
12/09/2019
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