Individual
MIKE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
945 SE UGLOW AVE, DALLAS, OR 97338-2642
(503) 837-1762
Mailing address
1170 BARNES AVE SE APT 222, SALEM, OR 97306-3560
(503) 949-1008
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
2627
OR
Other
Enumeration date
10/08/2024
Last updated
10/08/2024
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