Provider Demographics
NPI:1609416791
Name:WALLACE, CAMERON
Entity Type:Individual
Prefix:
First Name:CAMERON
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 1:24 PANDORA DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1912
Mailing Address - Country:US
Mailing Address - Phone:516-360-8049
Mailing Address - Fax:
Practice Address - Street 1:34 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:SOUTH FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2034
Practice Address - Country:US
Practice Address - Phone:516-755-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist