Individual
CASEY STEPHEN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPT
Contact information
Practice address
200 NEWPORT CENTER DR STE 213, NEWPORT BEACH, CA 92660-7503
(949) 644-1322
Mailing address
30059 BIG RANGE RD, CANYON LAKE, CA 92587-7660
(951) 809-6892
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
Other
Enumeration date
10/29/2017
Last updated
10/29/2017
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