Organization
THE WALLACE MEDICAL CONCERN
Active
Other names
Wallace, Wallace Medical Concern
Organization subpart
No
Provider details
NPI number
Authorized official
MS. LISA A. CLINE (CHIEF EXECUTIVE OFFICER)
(503) 489-1760
Entity
Organization
Contact information
Practice address
18633 SE STARK ST STE 401, PORTLAND, OR 97233-5468
(503) 489-1760
(503) 489-1763
Mailing address
18633 SE STARK ST STE 401, PORTLAND, OR 97233-5468
(503) 489-1760
(503) 489-1763
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
—
—
124Q00000X
Dental Hygienist
—
—
207Q00000X
Family Medicine Physician
—
—
261QC1500X
Community Health Clinic/Center
—
—
261QD0000X
Dental Clinic/Center
—
—
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
363LF0000X
Family Nurse Practitioner
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Enumeration date
11/18/2010
Last updated
02/24/2022
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