Organization
WALLACE'S PLACE
Active
Organization
WALLACE'S PLACE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CYNTHIA LYNN CLARK BSN RNC (EXECUTIVE DIRECTOR)
(623) 203-1148
Entity
Organization
Contact information
Practice address
9636 W OBERLIN WAY, PEORIA, AZ 85383-8750
(623) 203-1148
(623) 825-4639
Mailing address
9636 W OBERLIN WAY, PEORIA, AZ 85383-8750
(623) 203-1148
(623) 825-4639
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
304367
AHCCCS
AZ
Enumeration date
03/15/2008
Last updated
03/15/2008
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