Provider Demographics
NPI:1235360959
Name:VINSON, WALLACE L (RSA)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:L
Last Name:VINSON
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 S SCHMIDT RD STE G
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-3087
Mailing Address - Country:US
Mailing Address - Phone:630-754-7760
Mailing Address - Fax:630-754-7761
Practice Address - Street 1:260 S SCHMIDT RD STE G
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3087
Practice Address - Country:US
Practice Address - Phone:630-754-7760
Practice Address - Fax:630-754-7761
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000232174400000X
246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist