| Wallace | |
|
1165 N Main Ave Gresham OR 97030-5543 | |
| (503) 489-1760 | |
| (503) 489-1763 |
| Full Name | Wallace |
|---|---|
| Speciality | Family Medicine |
| Location | 1165 N Main Ave, Gresham, Oregon |
| Authorized Official Name and Position | Lisa Cline (CEO) |
| Authorized Official Contact | 5034891760 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Wallace 18633 Se Stark St Ste 401 Portland OR 97233-5468 Ph: (503) 489-1760 | Wallace 1165 N Main Ave Gresham OR 97030-5543 Ph: (503) 489-1760 |
| NPI Number | 1881429918 |
|---|---|
| Provider Enumeration Date | 09/06/2024 |
| Last Update Date | 09/06/2024 |
| Certification Date | 09/06/2024 |
| Medicare PECOS PAC ID | 2365680865 |
|---|---|
| Medicare Enrollment ID | O20250418000846 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1881429918 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 104100000X | Social Worker | () | Secondary |
| 124Q00000X | Dental Hygienist | () | Secondary |
| 207Q00000X | Family Medicine | () | Primary |
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