Provider Demographics
NPI:1295523090
Name:WALLACE, MACI (PT)
Entity type:Individual
Prefix:
First Name:MACI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 WOODMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2906
Mailing Address - Country:US
Mailing Address - Phone:334-387-0575
Mailing Address - Fax:
Practice Address - Street 1:4630 WOODMERE BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2906
Practice Address - Country:US
Practice Address - Phone:334-387-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist