1306868534 NPI number — KACEY L WALLACE DO

Table of content: KACEY L WALLACE DO (NPI 1306868534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306868534 NPI number — KACEY L WALLACE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
KACEY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306868534
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 W CHOCTAW AVE STE 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICKASHA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-544-2940
Provider Business Mailing Address Fax Number:
405-337-9632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 W CHOCTAW AVE STE 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICKASHA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-544-2940
Provider Business Practice Location Address Fax Number:
405-337-9632
Provider Enumeration Date:
07/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4339 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00331218 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200077860A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".