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General NPI Number Information
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NPI Number | 1164004420
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Entity Type | Individual
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Provider Name | TINA WALLACE
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Gender | Female
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Dates
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Enumeration Date | 04/26/2021
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Last Update Date | 04/26/2021
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Provider Practice Location Address
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Address Line | 2408 CARSON RD UNIT 1
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City | BIRMINGHAM
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State | AL
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Zip | 35215-3102
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Country | US
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Telephone | 205-757-0249
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Fax |
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Provider Business Mailing Address
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Address Line | 725 SUNHILL RD NW APT H
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City | CENTER POINT
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State | AL
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Zip | 35215-3043
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Country | US
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Telephone | 205-757-0249
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251F00000X
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Taxonomy Name | Home Infusion Agency
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License Number |
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License Number State |
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