Individual
B J WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2955 S BROADWAY, ENGLEWOOD, CO 80113-1526
(303) 788-1124
Mailing address
2955 S BROADWAY, ENGLEWOOD, CO 80113-1526
(303) 788-1124
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
11470
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
005083
KAISER-COMMERCIAL NUMBER
—
Enumeration date
02/16/2007
Last updated
10/05/2007
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