Individual
BRANDON WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
29900 SOUTHFIELD RD, SOUTHFIELD, MI 48076-2090
(248) 663-0400
(248) 621-5003
Mailing address
790 REMINGTON BLVD, BOLINGBROOK, IL 60440-4909
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
5501018432
MI
Other
Enumeration date
09/27/2017
Last updated
09/27/2017
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