Healthcare Provider Details

I. General information

NPI: 1164268306
Provider Name (Legal Business Name): ANTHONY CHASE WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/20/2024
Certification Date: 07/20/2024
Deactivation Date: 07/09/2024
Reactivation Date: 07/19/2024

III. Provider practice location address

2161 COURTLAND AVE
KETTERING OH
45420-2150
US

IV. Provider business mailing address

2161 COURTLAND AVE
KETTERING OH
45420-2150
US

V. Phone/Fax

Practice location:
  • Phone: 423-342-5226
  • Fax:
Mailing address:
  • Phone: 423-342-5226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: