Provider Demographics
NPI:1508814088
Name:THE WALLIS AGENCY, INC.
Entity Type:Organization
Organization Name:THE WALLIS AGENCY, INC.
Other - Org Name:ONYX HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:MCGREW
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:386-676-1118
Mailing Address - Street 1:1184 PELICAN BAY DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1381
Mailing Address - Country:US
Mailing Address - Phone:386-676-1118
Mailing Address - Fax:866-571-9365
Practice Address - Street 1:1184 PELICAN BAY DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-1381
Practice Address - Country:US
Practice Address - Phone:386-676-1118
Practice Address - Fax:866-571-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2016-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21282296251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21280096OtherFL LICENSE #