Provider Demographics
NPI:1467480939
Name:WALLACE, ROHN DALE (SUBMARINE IDC)
Entity Type:Individual
Prefix:
First Name:ROHN
Middle Name:DALE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:SUBMARINE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 WATERMAN RIDGE LN E
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-8001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USS OHIO SSGN 726 GOLD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98312
Practice Address - Country:US
Practice Address - Phone:360-476-8351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman