Provider Demographics
NPI:1790885648
Name:COLE, WALLACE RAY (DC)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:RAY
Last Name:COLE
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 1:615 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2117
Mailing Address - Country:US
Mailing Address - Phone:218-736-2875
Mailing Address - Fax:218-736-5353
Practice Address - Street 1:109 N MILL ST
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2134
Practice Address - Country:US
Practice Address - Phone:218-736-5353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1177111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor