CHARLES L WALLACE

FARMINGTON, NM
NPI1902140932
Entity TypeIndividual
GenderMale
Sole Proprietor ?No
Primary Taxonomy101YA0400X Counselor, Addiction (Substance Use Disorder)
(Licence: NM  3628)
Enumeration Date2012-11-15
Last Update Date2012-11-15
Business Address
-- CHARLES L WALLACE LADAC
2901 E. 20TH SUITE 104
FARMINGTON, NM 87499
Phone number: 505-326-0241
Mailing Address
-- CHARLES L WALLACE LADAC
P.O. BOX 3602
FARMINGTON, NM 87499
Phone number:
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