Provider Demographics
NPI:1942612551
Name:WALLACE, ERNEST
Entity Type:Individual
Prefix:MR
First Name:ERNEST
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 1:1716 NW CACHE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-4551
Mailing Address - Country:US
Mailing Address - Phone:580-574-8414
Mailing Address - Fax:
Practice Address - Street 1:1716 NW CACHE RD
Practice Address - Street 2:SUITE B
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-4551
Practice Address - Country:US
Practice Address - Phone:580-574-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-30
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor