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General NPI Number Information
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NPI Number | 1881429918
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Entity Type | Organization
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Legal Business Name | THE WALLACE MEDICAL CONCERN
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Dates
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Enumeration Date | 09/06/2024
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Last Update Date | 09/06/2024
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Provider Practice Location Address
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Address Line | 1165 N MAIN AVE
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City | GRESHAM
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State | OR
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Zip | 97030-5543
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Country | US
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Telephone | 503-489-1760
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Fax | 503-489-1763
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Provider Business Mailing Address
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Address Line | 18633 SE STARK ST STE 401
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City | PORTLAND
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State | OR
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Zip | 97233-5468
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Country | US
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Telephone | 503-489-1760
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Fax | 503-489-1763
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Authorized Official
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Title or Position | CEO
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Name | LISA CLINE
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Credential | MPH
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Telephone | 503-489-1760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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