Provider Demographics
NPI:1417683293
Name:WALLACE, ALLEN
Entity Type:Individual
Prefix:
First Name:ALLEN
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 1:6923 INDIANA AVE # 335
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-6111
Mailing Address - Country:US
Mailing Address - Phone:806-491-9778
Mailing Address - Fax:
Practice Address - Street 1:3506 E 14TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79403-6207
Practice Address - Country:US
Practice Address - Phone:806-777-3607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22954496172A00000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes347C00000XTransportation ServicesPrivate Vehicle
No172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1417683293Medicaid