Provider Demographics
NPI:1093255804
Name:WALLACE STREET PARTNERS LLC
Entity Type:Organization
Organization Name:WALLACE STREET PARTNERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SEIFERT
Authorized Official - Suffix:
Authorized Official - Credentials:DIPLOMA
Authorized Official - Phone:989-847-2188
Mailing Address - Street 1:211 W WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48806-9605
Mailing Address - Country:US
Mailing Address - Phone:989-847-2188
Mailing Address - Fax:989-847-2183
Practice Address - Street 1:211 W WALLACE ST
Practice Address - Street 2:
Practice Address - City:ASHLEY
Practice Address - State:MI
Practice Address - Zip Code:48806-9605
Practice Address - Country:US
Practice Address - Phone:989-847-2188
Practice Address - Fax:989-847-2183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL2902524783104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness