Individual
EARNEST WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
13136 WESTERN AVE, BLUE ISLAND, IL 60406-2423
(708) 974-5815
Mailing address
13136 WESTERN AVE, BLUE ISLAND, IL 60406-2423
(708) 974-5815
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Enumeration date
01/05/2015
Last updated
01/05/2015
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