1558323725 NPI number — MR. HEATH WADE WALLACE IDC

Table of content: MR. HEATH WADE WALLACE IDC (NPI 1558323725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558323725 NPI number — MR. HEATH WADE WALLACE IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
HEATH
Provider Middle Name:
WADE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

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:
1558323725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1973 BIG BOULDER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23456-6126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-471-1746
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
USS THEODORE ROOSEVELT CVN 71
Provider Second Line Business Practice Location Address:
MEDICAL DEPARTMENT
Provider Business Practice Location Address City Name:
FPO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09599 2871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-445-6230
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2006

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: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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