Provider Demographics
NPI:1558139428
Name:WALLACE, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 NE MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6019
Mailing Address - Country:US
Mailing Address - Phone:864-688-2018
Mailing Address - Fax:864-484-8493
Practice Address - Street 1:1314 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-1332
Practice Address - Country:US
Practice Address - Phone:864-688-2018
Practice Address - Fax:864-484-8493
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-2020253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care