Provider Demographics
NPI:1013002260
Name:PRIVETTE, WALLACE HAROLD JR (DC)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:HAROLD
Last Name:PRIVETTE
Suffix:JR
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 1:101B MEDICAL SCIENCES DR
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:SC
Mailing Address - Zip Code:29379-8609
Mailing Address - Country:US
Mailing Address - Phone:864-429-2912
Mailing Address - Fax:864-429-2912
Practice Address - Street 1:101B MEDICAL SCIENCES DR
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-8609
Practice Address - Country:US
Practice Address - Phone:864-429-2912
Practice Address - Fax:864-429-2912
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2204111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH198Medicaid
SCU723310281Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER