Provider Demographics
NPI:1902200918
Name:WALLACE HOME MEDICAL SUPPLIES
Entity Type:Organization
Organization Name:WALLACE HOME MEDICAL SUPPLIES
Other - Org Name:WALLACE HOME MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:TRAGO
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-238-3935
Mailing Address - Street 1:549 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-2510
Mailing Address - Country:US
Mailing Address - Phone:805-238-3935
Mailing Address - Fax:
Practice Address - Street 1:12310 LOS OSOS VALLEY RD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-7220
Practice Address - Country:US
Practice Address - Phone:805-439-4007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALLACE HOME MEDICAL SUPPLIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-20
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6091060002Medicare NSC