1144527870 NPI number — WALLACE PHYSICIAN SERVICES LLC

Table of content: JASON MARK HALEY LCDC (NPI 1316725138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144527870 NPI number — WALLACE PHYSICIAN SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLACE PHYSICIAN SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144527870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40535
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45240-0535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-384-9045
Provider Business Mailing Address Fax Number:
859-212-0949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1577 GOODMAN AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45224-1044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-403-3762
Provider Business Practice Location Address Fax Number:
513-521-6403
Provider Enumeration Date:
02/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
WAYMON
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
513-674-9601

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35-076674 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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