The Wallace Medical Concern

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

THE WALLACE MEDICAL CONCERN

Doing business as

Wallace

Practice address

1165 N Main Ave
Gresham, OR 97030-5543

Phone

(503) 489-1760

Fax

(503) 489-1763

NPI assigned

Sep 6, 2024

Last updated

Sep 6, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Lisa Cline, MPH

Title

Ceo

Phone

(503) 489-1760

Specialties & licenses 3

Addresses

Other names 1

• Wallace Doing business as

Medicare fee-for-service enrollment

Enrolled in OR

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881429918. Details of each certification follow.

• CCN 381051 Federally qualified health center · Active · Details

Federally qualified health center certification: CCN 381051

Legal name

THE WALLACE MEDICAL CONCERN

Doing business as

WALLACE

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Mar 27, 2025

Last certification

Mar 27, 2025

Ownership / control type

For profit – corporation

Organization structure

CorporationNon-profit

Enrollment address

1165 N Main Ave
Gresham, OR 97030-5543

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• The Wallace Medical Concern

  dba Wallace

  • Federally Qualified Health Center (FQHC)
  • Portland, OR
  • NPI 1841592110

  2365680865

  Same PAC ID

Tax ID family

The Wallace Medical Concern4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

• The Wallace Medical Concern

  dba Wallace

  • Dentist
  • Portland, OR
  • NPI 1215390091
  NPD tax ID
• The Wallace Medical Concern

  • Dentist
  • Portland, OR
  • NPI 1215390109
  NPD tax ID
• The Wallace Medical Concern

  • Dental Clinic/Center
  • Portland, OR
  • NPI 1558033118
  NPD tax ID

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Stuart J Currie, M.D.

  • Family Medicine Physician
  • Hillsboro, OR
  • NPI 1689645061

  Corporate Officer

  CMS ownership
• The Wallace Medical Concern

  dba Wallace

  • Federally Qualified Health Center (FQHC)
  • Portland, OR
  • NPI 1841592110

  5% Or Greater Direct Ownership Interest, Operational/Managerial Control

  CMS ownership

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Anna Jimenez, MD

  • Family Medicine Physician
  • Portland, OR
  • NPI 1649373424
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1725580800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1725580800000",
    "number": "1881429918",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18633 SE STARK ST STE 401",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972335468",
            "telephone_number": "503-489-1760",
            "fax_number": "503-489-1763"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1165 N MAIN AVE",
            "city": "GRESHAM",
            "state": "OR",
            "postal_code": "970305543",
            "telephone_number": "503-489-1760",
            "fax_number": "503-489-1763"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE WALLACE MEDICAL CONCERN",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-09-06",
        "last_updated": "2024-09-06",
        "certification_date": "2024-09-06",
        "status": "A",
        "authorized_official_last_name": "CLINE",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "503-489-1760",
        "authorized_official_credential": "MPH"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "",
            "desc": "Dental Hygienist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wallace",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jade Elisabeth Elaine Thayer
• The Denture Studio
• The Evangelical Lutheran Good Samaritan Society (Services@Home)
• The Evangelical Lutheran Good Samaritan Society (Good Samaritan Society - Fairlawn Village)
• The Sachiko Group, Inc
• Therapeutic Associates Inc (TAI Gresham Physical Therapy)
• Therapydia California Physical Therapy, PC.
• Therapyworks NW
• Harjot K Thind-Deol, MD
• Kristina Thomas, RN

• Family Medicine Physician in Gresham, OR
• Providers in Gresham, OR by specialty
• Family Medicine Physician in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 6, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.