Provider Demographics
NPI:1295118255
Name:DR TAMMY WALLACE LLC
Entity type:Organization
Organization Name:DR TAMMY WALLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:334-445-3937
Mailing Address - Street 1:1234 ANDREWS AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-3767
Mailing Address - Country:US
Mailing Address - Phone:334-445-3937
Mailing Address - Fax:334-445-3938
Practice Address - Street 1:1234 ANDREWS AVE
Practice Address - Street 2:SUITE E
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3767
Practice Address - Country:US
Practice Address - Phone:334-445-3937
Practice Address - Fax:334-445-3938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-C02-TA-822152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty