Provider Demographics
NPI:1902098981
Name:WALLACE GARDENS INC
Entity type:Organization
Organization Name:WALLACE GARDENS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:W
Authorized Official - Last Name:BIGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-521-5550
Mailing Address - Street 1:PO BOX 1179
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-1179
Mailing Address - Country:US
Mailing Address - Phone:910-521-5550
Mailing Address - Fax:
Practice Address - Street 1:1052 NE RAILROAD ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-0544
Practice Address - Country:US
Practice Address - Phone:910-521-5550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL 031 016310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805861Medicaid