| Wallace | |
|
18633 Se Stark St Ste 401 Portland OR 97233-5468 | |
| (503) 489-1760 | |
| (503) 489-1763 |
| Full Name | Wallace |
|---|---|
| Speciality | Clinic/Center |
| Location | 18633 Se Stark St Ste 401, Portland, Oregon |
| Authorized Official Name and Position | Lisa A. Cline (CHIEF EXECUTIVE OFFICER) |
| Authorized Official Contact | 5034891760 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Wallace 18633 Se Stark St Ste 401 Portland OR 97233-5468 Ph: (503) 489-1760 | Wallace 18633 Se Stark St Ste 401 Portland OR 97233-5468 Ph: (503) 489-1760 |
| NPI Number | 1841592110 |
|---|---|
| Provider Enumeration Date | 11/18/2010 |
| Last Update Date | 02/24/2022 |
| Medicare PECOS PAC ID | 2365680865 |
|---|---|
| Medicare Enrollment ID | O20130522000417 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1841592110 | NPI | - | NPPES |
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