=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780326744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALLACE & LEE INFUSION CENTER - A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2022
-----------------------------------------------------
Last Update Date | 06/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8750 WILSHIRE BLVD STE 210
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90211-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-652-0920
-----------------------------------------------------
Fax | 310-360-4812
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 18736
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90209-4736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-652-2284
-----------------------------------------------------
Fax | 310-855-9309
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS ADMINISTRATOR
-----------------------------------------------------
Name | ALISA CABRERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-652-2284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------