Healthcare Provider Details

I. General information

NPI: 1215096466
Provider Name (Legal Business Name): WALLACE HOME MEDICAL SUPPLIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 PARK ST
PASO ROBLES CA
93446-2160
US

IV. Provider business mailing address

1414 PARK ST
PASO ROBLES CA
93446-2160
US

V. Phone/Fax

Practice location:
  • Phone: 805-238-3935
  • Fax: 805-238-3974
Mailing address:
  • Phone: 805-238-3935
  • Fax: 805-238-3974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number18268
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number103383
License Number StateCA

VIII. Authorized Official

Name: MATTHEW TRAGO WALLACE
Title or Position: OWNER
Credential:
Phone: 805-238-3935