Provider Demographics
NPI:1376898684
Name:WALLACE, RICK M (FSP)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:M
Credentials:FSP
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 175
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73522-0175
Mailing Address - Country:US
Mailing Address - Phone:580-482-6229
Mailing Address - Fax:580-482-6239
Practice Address - Street 1:1313 N FORREST ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-2734
Practice Address - Country:US
Practice Address - Phone:580-482-6229
Practice Address - Fax:580-482-6239
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator