Provider Demographics
NPI:1679898647
Name:TERRANCE WALLACE SC
Entity Type:Organization
Organization Name:TERRANCE WALLACE SC
Other - Org Name:WALLACE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-386-7700
Mailing Address - Street 1:400 2ND ST S
Mailing Address - Street 2:SUITE 265
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-4000
Mailing Address - Country:US
Mailing Address - Phone:715-386-7700
Mailing Address - Fax:
Practice Address - Street 1:400 2ND ST S
Practice Address - Street 2:SUITE 265
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-4000
Practice Address - Country:US
Practice Address - Phone:715-386-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38765600Medicaid
WI35304Medicare PIN