Individual
KYLE EDWIN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1927 LINCOLN ST, BLAIR, NE 68008-1934
(531) 209-6113
Mailing address
1927 LINCOLN ST, BLAIR, NE 68008-1934
(531) 209-6113
Taxonomy
Speciality
Code
Description
License number
State
372600000X
Adult Companion
Primary
—
—
Other
Enumeration date
02/03/2025
Last updated
02/13/2025
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