Provider Demographics
NPI:1013188531
Name:WALLACE CHIROPRACTIC AND SPINAL REHAB, LLC
Entity Type:Organization
Organization Name:WALLACE CHIROPRACTIC AND SPINAL REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CA
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-394-8274
Mailing Address - Street 1:263 KELLEY ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2472
Mailing Address - Country:US
Mailing Address - Phone:843-394-8274
Mailing Address - Fax:843-394-1604
Practice Address - Street 1:263 KELLEY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2472
Practice Address - Country:US
Practice Address - Phone:843-394-8274
Practice Address - Fax:843-394-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1873111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH113Medicaid
SC6481000001Medicare NSC