Provider Demographics
NPI:1649441866
Name:WALLACE'S PLACE
Entity type:Organization
Organization Name:WALLACE'S PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:BSN RNC
Authorized Official - Phone:623-203-1148
Mailing Address - Street 1:9636 W OBERLIN WAY
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-8750
Mailing Address - Country:US
Mailing Address - Phone:623-203-1148
Mailing Address - Fax:623-825-4639
Practice Address - Street 1:9636 W OBERLIN WAY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-8750
Practice Address - Country:US
Practice Address - Phone:623-203-1148
Practice Address - Fax:623-825-4639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-15
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ304367OtherAHCCCS