Provider Demographics
NPI:1396891933
Name:WALLACE, JAMES LEWIS JR (CPO)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LEWIS
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:CPO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 24905
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4905
Mailing Address - Country:US
Mailing Address - Phone:336-397-2165
Mailing Address - Fax:336-397-2167
Practice Address - Street 1:1901 BRUNSWICK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2809
Practice Address - Country:US
Practice Address - Phone:704-348-4488
Practice Address - Fax:704-348-4496
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2010-07-23
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795261Medicaid