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General NPI Number Information
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NPI Number | 1508814088
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Entity Type | Organization
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Legal Business Name | THE WALLIS AGENCY, INC.
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Dates
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Enumeration Date | 05/05/2006
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Last Update Date | 11/25/2016
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Provider Practice Location Address
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Address Line | 1184 PELICAN BAY DR
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City | DAYTONA BEACH
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State | FL
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Zip | 32119-1381
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Country | US
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Telephone | 386-676-1118
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Fax | 866-571-9365
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Provider Business Mailing Address
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Address Line | 1184 PELICAN BAY DR
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City | DAYTONA BEACH
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State | FL
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Zip | 32119-1381
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Country | US
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Telephone | 386-676-1118
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Fax | 866-571-9365
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Authorized Official
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Title or Position | PRESIDENT/ADMINISTRATOR
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Name | COLLEEN MARGARET MCGREW
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Credential | R.N., B.S.N.
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Telephone | 386-676-1118
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 21282296
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License Number State | FL
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