Organization
DR. LARRY CHARLES WALLIS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LARRY CHARLES WALLIS O.D. (OWNER-OPTOMETRIST)
(856) 456-3925
Entity
Organization
Contact information
Practice address
14 N BROADWAY, POB93, GLOUCESTER CITY, NJ 08030-1507
(856) 456-3925
Mailing address
14 N BROADWAY, POB93, GLOUCESTER CITY, NJ 08030-1507
(856) 456-3925
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1695401
—
NJ
Enumeration date
04/29/2013
Last updated
04/29/2013
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