Provider Demographics
NPI:1184106866
Name:WALLACE FAMILY ADULT DAYCARE
Entity type:Organization
Organization Name:WALLACE FAMILY ADULT DAYCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCENE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-732-9159
Mailing Address - Street 1:1131 MEYER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-1826
Mailing Address - Country:US
Mailing Address - Phone:314-732-9159
Mailing Address - Fax:
Practice Address - Street 1:1131 MEYER ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-1826
Practice Address - Country:US
Practice Address - Phone:314-732-9159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care