Individual
DREW MICHAEL WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
17823 POPLAR GROVE RD, POPLAR GROVE, IL 61065-9014
(815) 765-3311
Mailing address
5061 LINDEN RD, #5303, ROCKFORD, IL 61109-5834
(815) 878-5391
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
200014924
IL
Other
Enumeration date
11/18/2014
Last updated
11/18/2014
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