Provider Demographics
NPI:1659460087
Name:WALLACE, SARA A (DC)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:A
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 1:17903 ROY ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2327
Mailing Address - Country:US
Mailing Address - Phone:708-251-5081
Mailing Address - Fax:
Practice Address - Street 1:17903 ROY ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2327
Practice Address - Country:US
Practice Address - Phone:708-251-5081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor