Provider Demographics
NPI:1063548410
Name:WALLACE FAMILY PRACTICE PA
Entity type:Organization
Organization Name:WALLACE FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-369-2903
Mailing Address - Street 1:3400 LEE BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-1309
Mailing Address - Country:US
Mailing Address - Phone:239-369-2903
Mailing Address - Fax:239-369-0500
Practice Address - Street 1:3400 LEE BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-1309
Practice Address - Country:US
Practice Address - Phone:239-369-2903
Practice Address - Fax:239-369-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8622261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU1026YMedicare PIN
FLH90975Medicare UPIN
FLAB224Medicare UPIN