Provider Demographics
NPI:1194052654
Name:WALLACE, ROBERT T (CPED)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3311
Mailing Address - Country:US
Mailing Address - Phone:704-334-1860
Mailing Address - Fax:704-347-2785
Practice Address - Street 1:2001 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3311
Practice Address - Country:US
Practice Address - Phone:704-334-1860
Practice Address - Fax:704-347-2785
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist