Provider Demographics
NPI:1215096466
Name:WALLACE HOME MEDICAL SUPPLIES
Entity type:Organization
Organization Name:WALLACE HOME MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:TRAGO
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-238-3935
Mailing Address - Street 1:1414 PARK ST
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-2160
Mailing Address - Country:US
Mailing Address - Phone:805-238-3935
Mailing Address - Fax:805-238-3974
Practice Address - Street 1:1414 PARK ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-2160
Practice Address - Country:US
Practice Address - Phone:805-238-3935
Practice Address - Fax:805-238-3974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103383332B00000X
CA18268332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ 08974 ZOtherBLUE SHIELD DME PROVIDER
CADME03195FMedicaid
CADME03195FMedicaid
CAZZZ 08974 ZOtherBLUE SHIELD DME PROVIDER
CA5130840001Medicare NSC