Provider Demographics
NPI:1114354156
Name:WALLACE, JUSTIN CORY (DIVE IDC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CORY
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DIVE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7586
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:699 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-7586
Practice Address - Country:US
Practice Address - Phone:760-845-8116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-06
Last Update Date:2013-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman