Healthcare Provider Details

I. General information

NPI: 1760527824
Provider Name (Legal Business Name): JIM WALLACE AND ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW ARLINGTON AVE SUITE D
LAWTON OK
73507-6570
US

IV. Provider business mailing address

202 S WASHITA AVE
WYNNEWOOD OK
73098-7820
US

V. Phone/Fax

Practice location:
  • Phone: 580-354-1555
  • Fax: 405-665-6396
Mailing address:
  • Phone: 405-665-4385
  • Fax: 405-665-6396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES E WALLACE
Title or Position: CEO FINANCIAL ADMINISTRATOR
Credential:
Phone: 405-665-4385