Individual
MR. RAYMOND WALLACE III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LPN
Contact information
Practice address
23861 SOUTH ROBIN RD, MANDEVILLE, LA 70448
(985) 624-4100
Mailing address
PO BOX 37, MANDEVILLE, LA 70470-0037
Taxonomy
Speciality
Code
Description
License number
State
164X00000X
Licensed Vocational Nurse
Primary
20101002
LA
Other
Enumeration date
02/15/2016
Last updated
02/15/2016
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