Individual
MR. CHARLES WALLACE WICKLIFFE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
11301 WILSHIRE BLVD, 117R, LOS ANGELES, CA 90073-1003
(310) 478-3711
Mailing address
5274 PARKGLEN AVE, LOS ANGELES, CA 90043-1030
(323) 299-9755
Taxonomy
Speciality
Code
Description
License number
State
225800000X
Recreation Therapist
Primary
—
—
Other
Enumeration date
11/08/2006
Last updated
07/08/2007
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