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Organization

HEADS

Active
Organization subpart
No

Provider details

NPI number
Authorized official
TED WALLACE MED (CEO)
(813) 754-5555
Entity
Organization

Contact information

Practice address
3244 MERLOT DR, LAKELAND, FL 33811-1810
(863) 614-7771
Mailing address
3244 MERLOT DR, LAKELAND, FL 33811-1810
(863) 614-7771

Taxonomy

Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
IMH13714
FL

Other

Enumeration date
11/18/2015
Last updated
11/18/2015
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