Healthcare Provider Details

I. General information

NPI: 1093255804
Provider Name (Legal Business Name): WALLACE STREET PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W WALLACE ST
ASHLEY MI
48806-9605
US

IV. Provider business mailing address

211 W WALLACE ST
ASHLEY MI
48806-9605
US

V. Phone/Fax

Practice location:
  • Phone: 989-847-2188
  • Fax: 989-847-2183
Mailing address:
  • Phone: 989-847-2188
  • Fax: 989-847-2183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberAL290252478
License Number StateMI

VIII. Authorized Official

Name: MRS. STEPHANIE LEE SEIFERT
Title or Position: ADMINISTRATOR
Credential: DIPLOMA
Phone: 989-847-2188