Provider Demographics
NPI:1639122658
Name:WALLACE, IRENE D (DC)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 MCHENRY RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1301
Mailing Address - Country:US
Mailing Address - Phone:847-276-2785
Mailing Address - Fax:
Practice Address - Street 1:1411 MCHENRY RD
Practice Address - Street 2:SUITE 225
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1301
Practice Address - Country:US
Practice Address - Phone:847-276-2785
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor