Provider Demographics
NPI:1669878625
Name:WALLACE, DREW MICHAEL (ATC)
Entity type:Individual
Prefix:
First Name:DREW
Middle Name:MICHAEL
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 1:5061 LINDEN RD
Mailing Address - Street 2:#5303
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-5834
Mailing Address - Country:US
Mailing Address - Phone:815-878-5391
Mailing Address - Fax:
Practice Address - Street 1:17823 POPLAR GROVE RD
Practice Address - Street 2:
Practice Address - City:POPLAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:61065-9014
Practice Address - Country:US
Practice Address - Phone:815-765-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2000149242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer