MEDICARE: JD WALLACE ENTERPRISES

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	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1346552478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JD WALLACE ENTERPRISES

Provider Business Mailing Address
First Line	:	PO BOX 43381
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349
Country	:	US
Telephone Number	:	323-558-2797
Fax Number	:	678-928-9427

Provider Business Practice Location Address
First Line	:	4286 MEMORIAL DR STE C
Second Line	:	SUITE B
City	:	DECATUR
State	:	GA
Zip	:	30032-1221
Country	:	US
Telephone Number	:	404-499-0342
Fax Number	:	678-928-9427

Authorized Official
Title or Position	:	CEO
Name	:	JOHN DAVID WALLACE
Credential	:
Telephone Number	:	323-558-2797

Provider Enumeration Date	:	07/06/2010
Last Update Date	:	07/25/2013

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