1932571056 NPI number — GABRIEL WAYNE WALLACE

Table of content: GABRIEL WAYNE WALLACE (NPI 1932571056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932571056 NPI number — GABRIEL WAYNE WALLACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
GABRIEL
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1932571056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4424
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48756-4424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-305-9629
Provider Business Mailing Address Fax Number:
989-873-1225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5208 MICHIBAN AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-305-9629
Provider Business Practice Location Address Fax Number:
989-873-1225
Provider Enumeration Date:
10/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 3747P1801X , with the licence number:  7666037 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7666037 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com