Provider Demographics
NPI:1598824096
Name:WALLACE, ALVIN JOSEPH (CSA)
Entity Type:Individual
Prefix:
First Name:ALVIN
Middle Name:JOSEPH
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:45167-1125
Mailing Address - Country:US
Mailing Address - Phone:937-392-1547
Mailing Address - Fax:
Practice Address - Street 1:20 MEDICAL VILLAGE DR STE 338
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5414
Practice Address - Country:US
Practice Address - Phone:859-341-2802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist