MEDICARE: AUGIE WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide	28613601	PA

General Provider Information

NPI Number	:	1083083455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUGIE WALLACE

Provider Business Mailing Address
First Line	:	4312 MAIN ST APT 316
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19127-1531
Country	:	US
Telephone Number	:	484-433-8208
Fax Number	:

Provider Business Practice Location Address
First Line	:	8600 W CHESTER PIKE STE 308
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-2629
Country	:	US
Telephone Number	:	484-433-8208
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2015
Last Update Date	:	09/13/2021

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