Provider Demographics
NPI:1790847937
Name:STEVENS, WALLACE TROY (DC)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:TROY
Last Name:STEVENS
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 1:1330 N LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-2022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1285 STRATFORD AVE
Practice Address - Street 2:SUITE I
Practice Address - City:DIXON
Practice Address - State:CA
Practice Address - Zip Code:95620-2026
Practice Address - Country:US
Practice Address - Phone:707-678-0170
Practice Address - Fax:707-678-8306
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0218140111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680461726OtherTAX ID