Basic Information
| Provider Information | |||||||||
| NPI: | 1043298425 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WALLACE MANAGEMENT CORPORATION | ||||||||
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| OtherOrganizationName: | REHABILITEX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16600 SPRAGUE ROAD | ||||||||
| Address2: | SUITE 365 | ||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162277700 | ||||||||
| FaxNumber: | 8668482496 | ||||||||
| Practice Location | |||||||||
| Address1: | 4175 STONERIDGE LANE | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145044733 | ||||||||
| FaxNumber: | 4404989725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | ZATCOFF | ||||||||
| AuthorizedOfficialFirstName: | MARSHA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8642443626 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.