MEDICARE: JIM WALLACE AND ASSOCIATES INC.

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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194860247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JIM WALLACE AND ASSOCIATES INC.

Provider Business Mailing Address
First Line	:	202 S WASHITA AVE
Second Line	:
City	:	WYNNEWOOD
State	:	OK
Zip	:	73098-7820
Country	:	US
Telephone Number	:	405-665-4385
Fax Number	:	405-665-6396

Provider Business Practice Location Address
First Line	:	925 15TH AVE NW
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1809
Country	:	US
Telephone Number	:	580-224-2830
Fax Number	:	405-665-6396

Authorized Official
Title or Position	:	OWNER/CEO/PRESIDENT/EXEC. DIRECTOR
Name	:	MS. TERESA GALE RUE-WALLACE
Credential	:	MASTERS SCIENCE
Telephone Number	:	405-306-8511

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	09/08/2021

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