Provider Demographics
NPI:1821371972
Name:DARIN WALLACE CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:DARIN WALLACE CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARIN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:765-932-5600
Mailing Address - Street 1:1520 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46173-2105
Mailing Address - Country:US
Mailing Address - Phone:765-932-5600
Mailing Address - Fax:765-932-5530
Practice Address - Street 1:1520 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173-2105
Practice Address - Country:US
Practice Address - Phone:765-932-5600
Practice Address - Fax:765-932-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001985A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201053650Medicaid
IN201053650Medicaid
INM100063439Medicare PIN