Individual
MR. ROBERT JASON WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
261 MACK AVE, DETROIT, MI 48201-2417
(313) 966-7246
Mailing address
8946 SAN MARCO BLVD, STERLING HEIGHTS, MI 48313-4866
(586) 488-6467
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2601001545
MI
Other
Enumeration date
10/24/2024
Last updated
10/24/2024
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