Healthcare Provider Details

I. General information

NPI: 1679900161
Provider Name (Legal Business Name): JOHN D WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 NW 53RD ST APT 222
MIAMI FL
33142
US

IV. Provider business mailing address

15286 SW 104TH ST APT 2-22
MIAMI FL
33196-3238
US

V. Phone/Fax

Practice location:
  • Phone: 904-418-3893
  • Fax:
Mailing address:
  • Phone: 904-418-3893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number235276
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number235276
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number235276
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: