Provider Demographics
NPI:1053426460
Name:WALLIS, SCOTT (DC)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:WALLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 W BEDFORD EULESS RD
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-3958
Mailing Address - Country:US
Mailing Address - Phone:817-285-8950
Mailing Address - Fax:
Practice Address - Street 1:416 W BEDFORD EULESS RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-3958
Practice Address - Country:US
Practice Address - Phone:817-285-8950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6346111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX47503Medicare UPIN
TX604035 GRP# 0001AEMedicare ID - Type Unspecified