MEDICARE: THE WALLIS AGENCY, INC.

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	251E00000X	Home Health Agency	21282296	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21280096	OTHER	FL	FL LICENSE #

General Provider Information

NPI Number	:	1508814088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE WALLIS AGENCY, INC.

Provider Business Mailing Address
First Line	:	1184 PELICAN BAY DR
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32119-1381
Country	:	US
Telephone Number	:	386-676-1118
Fax Number	:	866-571-9365

Provider Business Practice Location Address
First Line	:	1184 PELICAN BAY DR
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32119-1381
Country	:	US
Telephone Number	:	386-676-1118
Fax Number	:	866-571-9365

Authorized Official
Title or Position	:	PRESIDENT/ADMINISTRATOR
Name	:	COLLEEN MARGARET MCGREW
Credential	:	R.N., B.S.N.
Telephone Number	:	386-676-1118

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	11/25/2016

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Directions to “THE WALLIS AGENCY, INC. ” Practice Location

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