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1578207072
JUSTIN DALE WALLACE
PRYOR, OK
NPI
1578207072
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Entity Type
Individual
Gender
Male
Sole Proprietor ?
No
Primary Taxonomy
175T00000X Peer Specialist
(Licence: OK 175T00000X)
Enumeration Date
2022-04-21
Last Update Date
2022-04-21
Business Address
JUSTIN DALE WALLACE
109 N FAIRLAND ST
PRYOR, OK 74361-4205
Phone number: 918-925-1405
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Mailing Address
JUSTIN DALE WALLACE
109 N FAIRLAND ST
PRYOR, OK 74361-4205
Phone number:
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