Individual
ALLEN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3506 E 14TH ST, LUBBOCK, TX 79403-6207
(806) 777-3607
Mailing address
6923 INDIANA AVE # 335, LUBBOCK, TX 79413-6111
(806) 491-9778
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
22954496
TX
347C00000X
Private Vehicle
Primary
22954496
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1417683293
—
TX
Enumeration date
07/25/2022
Last updated
01/10/2023
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