Provider Demographics
NPI:1346552478
Name:JD WALLACE ENTERPRISES
Entity Type:Organization
Organization Name:JD WALLACE ENTERPRISES
Other - Org Name:FAMILY HEALTH CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-558-2797
Mailing Address - Street 1:PO BOX 43381
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349
Mailing Address - Country:US
Mailing Address - Phone:323-558-2797
Mailing Address - Fax:678-928-9427
Practice Address - Street 1:4286 MEMORIAL DR STE C
Practice Address - Street 2:SUITE B
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1221
Practice Address - Country:US
Practice Address - Phone:404-499-0342
Practice Address - Fax:678-928-9427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management