Healthcare Provider Details

I. General information

NPI: 1124172036
Provider Name (Legal Business Name): MARY ANN WALLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 TROY STREET
DAYTON OH
45404
US

IV. Provider business mailing address

900 TROY STREET
DAYTON OH
45404
US

V. Phone/Fax

Practice location:
  • Phone: 937-443-0405
  • Fax: 937-454-0390
Mailing address:
  • Phone: 937-443-0405
  • Fax: 937-454-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number20060784
License Number StateOH

VIII. Authorized Official

Name: MRS. MARY ANN WALLACE
Title or Position: CEO OWNER OPERATOR
Credential:
Phone: 937-443-0405