Provider Demographics
NPI:1003126236
Name:DREW G. WALLACE, INC.
Entity Type:Organization
Organization Name:DREW G. WALLACE, INC.
Other - Org Name:ANGELO CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:325-949-7878
Mailing Address - Street 1:1801 W AVENUE N
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-4628
Mailing Address - Country:US
Mailing Address - Phone:325-949-7878
Mailing Address - Fax:325-944-7703
Practice Address - Street 1:1801 W AVENUE N
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-4628
Practice Address - Country:US
Practice Address - Phone:325-949-7878
Practice Address - Fax:325-944-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6345111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty