Provider Demographics
NPI:1316382740
Name:DR. LARRY CHARLES WALLIS LLC
Entity Type:Organization
Organization Name:DR. LARRY CHARLES WALLIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:856-456-3925
Mailing Address - Street 1:14 N BROADWAY
Mailing Address - Street 2:POB93
Mailing Address - City:GLOUCESTER CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08030-1507
Mailing Address - Country:US
Mailing Address - Phone:856-456-3925
Mailing Address - Fax:
Practice Address - Street 1:14 N BROADWAY
Practice Address - Street 2:POB93
Practice Address - City:GLOUCESTER CITY
Practice Address - State:NJ
Practice Address - Zip Code:08030-1507
Practice Address - Country:US
Practice Address - Phone:856-456-3925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1695401Medicaid
NJ1695401Medicaid
NJT77821Medicare UPIN