Provider Demographics
NPI:1194928481
Name:WALLACE, JIM F (PT)
Entity type:Individual
Prefix:MR
First Name:JIM
Middle Name:F
Last Name:WALLACE
Suffix:
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 1:16693 GRAY WOLF LN
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97707-2548
Mailing Address - Country:US
Mailing Address - Phone:503-956-8141
Mailing Address - Fax:
Practice Address - Street 1:404 NE PENN AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4264
Practice Address - Country:US
Practice Address - Phone:541-318-7041
Practice Address - Fax:541-388-3711
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR29482251X0800X
OR02948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500694596Medicaid
ORR184863Medicare PIN