MEDICARE: MR. ANTHONY RAY 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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1851574347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANTHONY RAY WALLACE

Provider Business Mailing Address
First Line	:	9150 EAST IMPERIAL HIGHWAY
Second Line	:	ROOM P31
City	:	DOWNEY
State	:	CA
Zip	:	90242
Country	:	US
Telephone Number	:	562-940-3694
Fax Number	:	562-658-4725

Provider Business Practice Location Address
First Line	:	4849 CIVIC CENTER WAY
Second Line	:
City	:	EAST LOS ANGELES
State	:	CA
Zip	:	90022
Country	:	US
Telephone Number	:	323-780-2125
Fax Number	:

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

Provider Enumeration Date	:	12/07/2007
Last Update Date	:	12/07/2007

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