THE WALLACE MEDICAL CONCERN

Provider Demographics

• NPI: 1841592110
• Name: THE WALLACE MEDICAL CONCERN
• Entity Type: Organization
• Organization Name: THE WALLACE MEDICAL CONCERN
• Other - Org Name: WALLACE
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: CHIEF EXECUTIVE OFFICER
• Authorized Official - Prefix: MS
• Authorized Official - First Name: LISA
• Authorized Official - Middle Name: A
• Authorized Official - Last Name: CLINE
• Authorized Official - Phone: 503-489-1760
• Mailing Address - Street 1: 18633 SE STARK ST STE 401
• Mailing Address - City: PORTLAND
• Mailing Address - State: OR
• Mailing Address - Zip Code: 97233-5468
• Mailing Address - Country: US
• Mailing Address - Phone: 503-489-1760
• Mailing Address - Fax: 503-489-1763
• Practice Address - Street 1: 18633 SE STARK ST STE 401
• Practice Address - City: PORTLAND
• Practice Address - State: OR
• Practice Address - Zip Code: 97233-5468
• Practice Address - Country: US
• Practice Address - Phone: 503-489-1760
• Practice Address - Fax: 503-489-1763
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2010-11-18
• Last Update Date: 2022-02-24

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	261QF0400X	Ambulatory Health Care Facilities	Clinic/Center	Federally Qualified Health Center (FQHC)	Group - Multi-Specialty
No	122300000X	Dental Providers	Dentist		Group - Multi-Specialty
No	124Q00000X	Dental Providers	Dental Hygienist		Group - Multi-Specialty
No	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	261QC1500X	Ambulatory Health Care Facilities	Clinic/Center	Community Health
No	261QD0000X	Ambulatory Health Care Facilities	Clinic/Center	Dental
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty
No	363LP0808X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Psychiatric/Mental Health	Group - Multi-Specialty