Provider Demographics
NPI:1013158831
Name:WALL, JIM
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:WALL
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 1:6706 SEA ROBIN PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2548
Mailing Address - Country:US
Mailing Address - Phone:813-758-0319
Mailing Address - Fax:866-463-4875
Practice Address - Street 1:6706 SEA ROBIN PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2548
Practice Address - Country:US
Practice Address - Phone:813-758-0319
Practice Address - Fax:866-463-4875
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies