Provider Demographics
NPI:1003889148
Name:WALLACE, DENVER R (DC)
Entity Type:Individual
Prefix:DR
First Name:DENVER
Middle Name:R
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 1:430 SOUTH ELM STREET
Mailing Address - Street 2:P.O. BOX 1177
Mailing Address - City:BALD KNOB
Mailing Address - State:AR
Mailing Address - Zip Code:72010-1177
Mailing Address - Country:US
Mailing Address - Phone:501-724-5614
Mailing Address - Fax:501-724-5614
Practice Address - Street 1:430 SOUTH ELM STREET
Practice Address - Street 2:
Practice Address - City:BALD KNOB
Practice Address - State:AR
Practice Address - Zip Code:72010-1177
Practice Address - Country:US
Practice Address - Phone:501-724-5614
Practice Address - Fax:501-724-5614
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1319111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR59306Medicare ID - Type Unspecified