Individual
MR. ALLEN KEITH WALLACE JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1600 RIVER SHORE DR APT 2040, LOUISVILLE, KY 40206-1913
(901) 212-9333
Mailing address
1600 RIVER SHORE DR APT 2040, LOUISVILLE, KY 40206-1913
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
QUP020M92733
ANTHEM
KY
Enumeration date
02/18/2021
Last updated
02/18/2021
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