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General NPI Number Information
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NPI Number | 1205347812
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Entity Type | Organization
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Legal Business Name | D WALLACE HEALTH PROMOTION AND WELLNESS
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Dates
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Enumeration Date | 10/23/2017
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Last Update Date | 10/23/2017
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Provider Practice Location Address
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Address Line | 15730 MOK AVE
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City | EASTPOINTE
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State | MI
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Zip | 48021-2367
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Country | US
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Telephone | 313-415-1538
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Fax | 586-585-9555
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Provider Business Mailing Address
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Address Line | 15730 MOK AVE
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City | EASTPOINTE
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State | MI
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Zip | 48021-2367
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Country | US
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Telephone | 313-415-1538
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Fax | 586-585-9555
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Authorized Official
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Title or Position | FOUNDER/CHIEF ADMINISTATOR
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Name | MRS. DIONNE LANETTE WALLACE
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Credential | MSN RN CNL
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Telephone | 586-241-7088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 4704260135
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License Number State | MI
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