# THE WALLACE MEDICAL CONCERN

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Wallace
- **Organization subpart:** No

## Provider details

- **NPI number:** 1881429918
- **Authorized official:** LISA CLINE MPH (CEO)
- **Authorized official phone:** (503) 489-1760

## Contact information

- **Practice address:** 1165 N MAIN AVE, GRESHAM, OR 97030-5543
- **Practice address phone:** (503) 489-1760
- **Practice address fax:** (503) 489-1763
- **Mailing address:** 18633 SE STARK ST STE 401, PORTLAND, OR 97233-5468
- **Mailing address phone:** (503) 489-1760
- **Mailing address fax:** (503) 489-1763

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 104100000X | Social Worker | — | NULL | — |
| 104100000X | Social Worker | — | — | — |
| 124Q00000X | Dental Hygienist | — | NULL | — |
| 124Q00000X | Dental Hygienist | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 09/06/2024
- **Last updated:** 09/06/2024