Provider Demographics
NPI:1841935293
Name:HESTER, WALLACE III
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:HESTER
Suffix:III
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 1:1738 LAKEFRONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAST CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-2123
Mailing Address - Country:US
Mailing Address - Phone:216-463-0966
Mailing Address - Fax:
Practice Address - Street 1:1738 LAKEFRONT AVE
Practice Address - Street 2:
Practice Address - City:EAST CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-2123
Practice Address - Country:US
Practice Address - Phone:216-463-0966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-30
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)