Individual
MR. GUY ROBERT WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.T.
Contact information
Practice address
1222 WOODLAND DR, ELIZABETHTOWN, KY 42701-2710
(270) 234-1569
(270) 234-0680
Mailing address
403 N MILES ST, ELIZABETHTOWN, KY 42701-1834
(270) 360-9129
(270) 234-8197
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
002884
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000176410
BLUE CROSS
KY
01
—
2439083000
PASSPORT
KY
05
—
87000048
—
KY
Enumeration date
01/17/2007
Last updated
06/02/2008
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