Provider Demographics
NPI:1417386350
Name:WALLACE, TREVOR
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 N DOLLNER CT
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-1932
Mailing Address - Country:US
Mailing Address - Phone:559-731-2833
Mailing Address - Fax:
Practice Address - Street 1:315 RECORD ST STE 103
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-3327
Practice Address - Country:US
Practice Address - Phone:775-405-4111
Practice Address - Fax:775-622-8611
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator