Provider Demographics
NPI:1336825926
Name:WALLACE, BRYAN MICHAEL (SOIDC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:MICHAEL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC BOX 20184
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542
Mailing Address - Country:US
Mailing Address - Phone:910-440-2504
Mailing Address - Fax:
Practice Address - Street 1:1ST MARINE RAIDER BATTALION
Practice Address - Street 2:STONE BAY
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-440-2504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman