Provider Demographics
NPI:1083226005
Name:WALLACE, JAMES D
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 211
Mailing Address - Street 2:
Mailing Address - City:FOSTER
Mailing Address - State:WV
Mailing Address - Zip Code:25081-0211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 DON DALE DR
Practice Address - Street 2:
Practice Address - City:FOSTER
Practice Address - State:WV
Practice Address - Zip Code:25081
Practice Address - Country:US
Practice Address - Phone:304-688-7849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant