Provider Demographics
NPI:1053736439
Name:WALLACE CHIROPRACTIC, PC
Entity type:Organization
Organization Name:WALLACE CHIROPRACTIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JANEEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-245-4995
Mailing Address - Street 1:6610 E BASELINE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4440
Mailing Address - Country:US
Mailing Address - Phone:480-245-4995
Mailing Address - Fax:
Practice Address - Street 1:6610 E BASELINE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4440
Practice Address - Country:US
Practice Address - Phone:480-245-4995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7558111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ141374Medicare UPIN