Provider Demographics
NPI:1215021829
Name:WEST, WALLACE CHRISTOPHER (DC)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:CHRISTOPHER
Last Name:WEST
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 1:4700 HARDY ST.
Mailing Address - Street 2:SUITE M
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1300
Mailing Address - Country:US
Mailing Address - Phone:601-261-5599
Mailing Address - Fax:601-261-3295
Practice Address - Street 1:4700 HARDY ST.
Practice Address - Street 2:SUITE M
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1300
Practice Address - Country:US
Practice Address - Phone:601-261-5599
Practice Address - Fax:601-261-3295
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS106317OtherHEALTH PARTNERS
MS4666264OtherAETNA
MS00114920Medicaid
MS44-32003OtherUNITED HEALTH CARE NUMBER