Individual
EARNEST WALLACE III
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSS
Contact information
Practice address
5201 SW WESTGATE DR STE 100, PORTLAND, OR 97221-2424
(469) 297-0096
Mailing address
423 MCKINLEY ST, CEDAR HILL, TX 75104-2287
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
111712
OR
Other
Enumeration date
07/15/2024
Last updated
07/15/2024
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