Individual
CODY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
12N854 MEADOWLARK DR, HAMPSHIRE, IL 60140-8919
(847) 652-6743
Mailing address
12N854 MEADOWLARK DR, HAMPSHIRE, IL 60140-8919
(847) 652-6743
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
—
—
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
02/02/2017
Last updated
02/02/2017
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