Provider Demographics
NPI:1043298425
Name:WALLACE MANAGEMENT CORPORATION
Entity type:Organization
Organization Name:WALLACE MANAGEMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZATCOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-244-3626
Mailing Address - Street 1:16600 SPRAGUE ROAD
Mailing Address - Street 2:SUITE 365
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130
Mailing Address - Country:US
Mailing Address - Phone:216-227-7700
Mailing Address - Fax:866-848-2496
Practice Address - Street 1:4175 STONERIDGE LANE
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017
Practice Address - Country:US
Practice Address - Phone:614-504-4733
Practice Address - Fax:440-498-9725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH366653Medicare Oscar/Certification