Provider Demographics
NPI:1609998129
Name:WALLACE, EDWARD C (DC,ND)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DC,ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5305 HERBERT HOOVER HWY NE
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:IA
Mailing Address - Zip Code:52358-9543
Mailing Address - Country:US
Mailing Address - Phone:319-643-5942
Mailing Address - Fax:319-643-5942
Practice Address - Street 1:5305 HERBERT HOOVER HWY NE
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:IA
Practice Address - Zip Code:52358-9543
Practice Address - Country:US
Practice Address - Phone:319-643-5942
Practice Address - Fax:319-643-5942
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05650111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA11815Medicare ID - Type Unspecified