Provider Demographics
NPI:1306855663
Name:WADE, WALLACE C (DC)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:C
Last Name:WADE
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 1:12084 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-5682
Mailing Address - Country:US
Mailing Address - Phone:813-265-4135
Mailing Address - Fax:813-265-3904
Practice Address - Street 1:12084 ANDERSON RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-5682
Practice Address - Country:US
Practice Address - Phone:813-265-4135
Practice Address - Fax:813-265-3904
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4075111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH4075OtherSTATE LICENSE
FLT56008Medicare UPIN
FL88878Medicare ID - Type Unspecified