Healthcare Provider Details

I. General information

NPI: 1720941552
Provider Name (Legal Business Name): ROMALE WALLACE SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 E 329TH ST
WILLOWICK OH
44095-3225
US

IV. Provider business mailing address

226 E 329TH ST
WILLOWICK OH
44095-3225
US

V. Phone/Fax

Practice location:
  • Phone: 440-589-0139
  • Fax:
Mailing address:
  • Phone: 440-589-0139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberSS826227
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: