MEDICARE: MRS. LORNA C WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1063107811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LORNA C WALLACE

Provider Business Mailing Address
First Line	:	2259 MOUNT VERNON BLVD
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-3661
Country	:	US
Telephone Number	:	216-415-1587
Fax Number	:

Provider Business Practice Location Address
First Line	:	2259 MOUNT VERNON BLVD
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-3661
Country	:	US
Telephone Number	:	216-415-1587
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2023
Last Update Date	:	04/07/2023

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