Provider Demographics
NPI:1053126706
Name:WALLACE, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6732 S 73RD STREET CIR
Mailing Address - Street 2:
Mailing Address - City:RALSTON
Mailing Address - State:NE
Mailing Address - Zip Code:68127-4387
Mailing Address - Country:US
Mailing Address - Phone:531-772-8700
Mailing Address - Fax:
Practice Address - Street 1:6732 S 73RD STREET CIR
Practice Address - Street 2:
Practice Address - City:RALSTON
Practice Address - State:NE
Practice Address - Zip Code:68127-4387
Practice Address - Country:US
Practice Address - Phone:531-772-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities