Basic Information
| Provider Information | |||||||||
| NPI: | 1720086838 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANTHONY WALLACE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PASO ROBLES PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5255 EL CAMINO REAL STE C | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934223351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052370272 | ||||||||
| FaxNumber: | 8052372416 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 PARK ST | ||||||||
| Address2: | |||||||||
| City: | PASO ROBLES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934462160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052370272 | ||||||||
| FaxNumber: | 8052372416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8052370272 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 10294 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.