Provider Demographics
NPI:1326550518
Name:WALLACE, CASEY STEPHEN (DPT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:STEPHEN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30059 BIG RANGE RD
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-7660
Mailing Address - Country:US
Mailing Address - Phone:951-809-6892
Mailing Address - Fax:
Practice Address - Street 1:200 NEWPORT CENTER DR STE 213
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7503
Practice Address - Country:US
Practice Address - Phone:949-644-1322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-29
Last Update Date:2017-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist