Provider Demographics
NPI:1932477320
Name:WALL, BRUCE ALLEN JR (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ALLEN
Last Name:WALL
Suffix:JR
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:451 HEALTH PKWY
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-8242
Mailing Address - Country:US
Mailing Address - Phone:269-657-1490
Mailing Address - Fax:269-657-1444
Practice Address - Street 1:451 HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-8242
Practice Address - Country:US
Practice Address - Phone:269-657-1490
Practice Address - Fax:269-657-1444
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501015692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist