Most Relevant Information
Provider Data
| NPI Number: | 1003339094 |
| Provider Name: | TREVOR DEWITT WALLACE |
| Entity Type: | Individual |
| Taxonomy Code: | 171W00000X |
| Specialty: | Contractor |
| License Number: |
Most Important Dates
| Enumeration Date: | 07/20/2017 |
| Last Updated: | 07/21/2022 |
Provider Practice Location
571 EVA KENNEDY RD APT 8
SUWANEE
GA
300243008
Practice Location Phone/Fax
| Phone: | 7703691497 |
| Fax: |
Provider Mailing Location
571 EVA KENNEDY RD APT 8
SUWANEE
GA
300243008
Provider Mailing Phone/Fax
| Phone: | 7703691497 |
| Fax: |