Provider Demographics
NPI:1518401801
Name:WALLIS CHIROPRACTIC HEALTH CENTER PLLC
Entity Type:Organization
Organization Name:WALLIS CHIROPRACTIC HEALTH CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-427-3550
Mailing Address - Street 1:10985 MIDDLEBELT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3056
Mailing Address - Country:US
Mailing Address - Phone:734-427-3550
Mailing Address - Fax:734-422-5567
Practice Address - Street 1:10985 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-3056
Practice Address - Country:US
Practice Address - Phone:734-427-3550
Practice Address - Fax:734-422-5567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008685111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH25086003Medicare PIN