Organization
LYDIA V. WALLACE, D.O., P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LYDIA VALLADARES WALLACE D.O. (OWNER)
(954) 721-8202
Entity
Organization
Contact information
Practice address
3021 N 66TH AVE, HOLLYWOOD, FL 33024-2925
(754) 281-8202
Mailing address
3021 N 66TH AVE, HOLLYWOOD, FL 33024-2925
(754) 281-8202
Taxonomy
Speciality
Code
Description
License number
State
261QC1500X
Community Health Clinic/Center
Primary
OS 10688
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
352349931
—
FL
Enumeration date
03/07/2012
Last updated
03/07/2012
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