Individual
GABRIEL WAYNE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
5208 MICHIBAN AVE., PRESCOTT, MI 48756
(989) 305-9629
(989) 873-1225
Mailing address
PO BOX 4424, PRESCOTT, MI 48756-4424
(989) 305-9629
(989) 873-1225
Taxonomy
Speciality
Code
Description
License number
State
3747P1801X
Personal Care Attendant
Primary
7666037
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7666037
—
MI
Enumeration date
10/28/2015
Last updated
10/28/2015
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