Provider Demographics
NPI:1124172036
Name:MARY ANN WALLACE
Entity type:Organization
Organization Name:MARY ANN WALLACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-443-0405
Mailing Address - Street 1:900 TROY STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404
Mailing Address - Country:US
Mailing Address - Phone:937-443-0405
Mailing Address - Fax:937-454-0390
Practice Address - Street 1:900 TROY STREET
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404
Practice Address - Country:US
Practice Address - Phone:937-443-0405
Practice Address - Fax:937-454-0390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20060784332U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0959379Medicaid