Individual
VINCENT WALLACE
Active
Individual
VINCENT WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MA
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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