Provider Demographics
NPI:1265100184
Name:WALLACE, KEVIN (ATC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:DECHERD
Mailing Address - State:TN
Mailing Address - Zip Code:37324-3906
Mailing Address - Country:US
Mailing Address - Phone:931-691-9262
Mailing Address - Fax:
Practice Address - Street 1:100 BIBLE CROSSING RD
Practice Address - Street 2:
Practice Address - City:DECHARD
Practice Address - State:TN
Practice Address - Zip Code:37324
Practice Address - Country:US
Practice Address - Phone:931-962-9947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000002932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer