| Organization Name: | WALLACE FAMILY PRACTICE PA |
| NPI Number: | 1063548410 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TASHA B. WALLACE (PRESIDENT) |
| Mailing Address: | 3400 Lee Blvd Suite 108 Lehigh Acres |
| State: | FL US |
| Postal Code: | 339711309 |
| Phone Number: | 2393692903 |
| Fax Number: | 2393690500 |
| NPI Enumeration Date: | 02/27/2007 |
| NPI Last Update Date: | 12/29/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261Q00000X |
| License Number: | OS8622 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A facility or distinct part of one used for the diagnosis and treatment of outpatients. "Clinic/Center" is irregularly defined, sometimes being limited to organizations serving specialized treatment requirements or distinct patient/client groups (e.g., radiology, poor, and public health). |