Provider Demographics
NPI:1578523734
Name:WALLACE, HARRY L (DC)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:L
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 1:2001 52ND AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6368
Mailing Address - Country:US
Mailing Address - Phone:309-764-4901
Mailing Address - Fax:
Practice Address - Street 1:2001 52ND AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6368
Practice Address - Country:US
Practice Address - Phone:309-764-4901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04667111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL527080OtherMEDICARE
IL038003364Medicaid
IL323290OtherBLUE CROSS BLUE SHIELD IL
ILT95935Medicare UPIN