Provider Demographics
NPI:1386868487
Name:WALLACE, DAVID STUART (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:STUART
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 1:2330 HIGHWAY 94 SOUTH OUTER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-8301
Mailing Address - Country:US
Mailing Address - Phone:636-498-2346
Mailing Address - Fax:
Practice Address - Street 1:2330 HIGHWAY 94 SOUTH OUTER RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-8301
Practice Address - Country:US
Practice Address - Phone:636-498-2346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006811111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO131625OtherBLUECROSS BLUESHIELD
MO3391509OtherCIGNA
MO4400088OtherUNITED HEALTHCARE
MO4400088OtherUNITED HEALTHCARE