Provider Demographics
NPI:1003866419
Name:WALLACE, JEFFREY NEIL (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:NEIL
Last Name:WALLACE
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 1:330 140 VILLAGE RD
Mailing Address - Street 2:UNIT 9A
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6127
Mailing Address - Country:US
Mailing Address - Phone:410-876-8881
Mailing Address - Fax:410-848-6343
Practice Address - Street 1:330 140 VILLAGE RD
Practice Address - Street 2:UNIT 9A
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6127
Practice Address - Country:US
Practice Address - Phone:410-876-8881
Practice Address - Fax:410-848-6343
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSO1780111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD228PMedicare UPIN