Individual
VINCENT WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MA
Contact information
Practice address
226 W ONTARIO ST, CHICAGO, IL 60654-3619
(312) 912-7008
(312) 533-2842
Mailing address
19050 MAPLE AVE, COUNTRY CLUB HILLS, IL 60478-5737
(708) 612-3784
Taxonomy
Speciality
Code
Description
License number
State
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
—
—
Other
Enumeration date
02/06/2020
Last updated
02/06/2020
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