Provider Demographics
NPI:1063744811
Name:WALLACE, ROBERT J III (PT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WALLACE
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 LEGEND POINT DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-2412
Mailing Address - Country:US
Mailing Address - Phone:210-310-1538
Mailing Address - Fax:
Practice Address - Street 1:2004 10TH ST
Practice Address - Street 2:
Practice Address - City:FLORESVILLE
Practice Address - State:TX
Practice Address - Zip Code:78114-2770
Practice Address - Country:US
Practice Address - Phone:830-393-8800
Practice Address - Fax:830-393-8828
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1132512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist