Provider Demographics
NPI:1780633420
Name:WALLACE, TYRONE D (DC)
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:D
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 1:263 KELLEY ST
Mailing Address - Street 2:STE 100
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2450
Mailing Address - Country:US
Mailing Address - Phone:843-394-8274
Mailing Address - Fax:843-394-1604
Practice Address - Street 1:263 KELLEY ST
Practice Address - Street 2:STE 100
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2450
Practice Address - Country:US
Practice Address - Phone:843-394-8274
Practice Address - Fax:843-394-1604
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1873111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1873Medicaid
SC571012172OtherBC
SCU53372Medicare UPIN
SC571012172OtherBC
SC6481000001Medicare NSC