Provider Demographics
NPI:1598083495
Name:WALLACE, BRIAN WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WILLIAM
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 1:98 SENEY DR
Mailing Address - Street 2:
Mailing Address - City:BERNARDSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07924-1849
Mailing Address - Country:US
Mailing Address - Phone:908-221-0808
Mailing Address - Fax:
Practice Address - Street 1:139 MORRISTOWN RD
Practice Address - Street 2:
Practice Address - City:BERNARDSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07924-2633
Practice Address - Country:US
Practice Address - Phone:908-221-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00676500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor