Individual
DONALD W WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3003 PERSHING CT STE 101, DECATUR, IL 62526-6323
(217) 330-9654
Mailing address
3113 FLINTLOCK PATH, SAINT CHARLES, MO 63301-3902
(314) 761-7510
Taxonomy
Speciality
Code
Description
License number
State
237700000X
Hearing Instrument Specialist
2013004501
MO
237700000X
Hearing Instrument Specialist
Primary
3320
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2013004501
HEARING AID DISPENSER LICENSE
MO
01
—
3320
HEARING AID DISPENSER LICENCE
IL
Enumeration date
09/20/2013
Last updated
07/22/2021
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