Healthcare Provider Details

I. General information

NPI: 1447167440
Provider Name (Legal Business Name): CLEVELAND WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2513 CAMDEN PARK CIR
DAVENPORT FL
33837-1801
US

IV. Provider business mailing address

2513 CAMDEN PARK CIR
DAVENPORT FL
33837-1801
US

V. Phone/Fax

Practice location:
  • Phone: 863-312-2612
  • Fax:
Mailing address:
  • Phone: 863-312-2612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: