Provider Information for 1932610623
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LOWELL WALLACE
Sex: Male
NPI: 1932610623
Last Updated: 2018-03-17
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1932610623 | ||||||||
| Enumeration Date | 2017-10-20 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 1120 E MAIN ST STE 24 PHILADELPHIA, MS 39350-2300 United States Phone: 601-781-8677 | Fax:601-207-7720 | ||||||||
| Primary Practice Address | 1120 E MAIN ST STE 24 PHILADELPHIA, MS 39350-2300 United States Phone: 601-781-8677 | Fax:601-207-7720 | ||||||||
| Secondary Practice Address(es) | 4715 24TH PL | ||||||||
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