Individual
JOHN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
6732 S 73RD STREET CIR, RALSTON, NE 68127-4387
(531) 772-8700
Mailing address
6732 S 73RD STREET CIR, RALSTON, NE 68127-4387
(531) 772-8700
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Enumeration date
02/10/2025
Last updated
02/11/2025
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