Provider Demographics
NPI:1609115039
Name:MELODIE K. WALLACE, O.D.
Entity Type:Organization
Organization Name:MELODIE K. WALLACE, O.D.
Other - Org Name:FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELODIE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:210-494-3146
Mailing Address - Street 1:17700 N US HIGHWAY 281
Mailing Address - Street 2:SUITE #136
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1404
Mailing Address - Country:US
Mailing Address - Phone:210-494-3146
Mailing Address - Fax:
Practice Address - Street 1:17700 N US HIGHWAY 281
Practice Address - Street 2:SUITE #136
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1404
Practice Address - Country:US
Practice Address - Phone:210-494-3146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3539T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty