Provider Demographics
NPI:1922412766
Name:DR MARK WALLACE PLLC
Entity Type:Organization
Organization Name:DR MARK WALLACE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:901-861-1212
Mailing Address - Street 1:2140 W POPLAR AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-0624
Mailing Address - Country:US
Mailing Address - Phone:901-861-1212
Mailing Address - Fax:901-861-1283
Practice Address - Street 1:2140 W POPLAR AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0624
Practice Address - Country:US
Practice Address - Phone:901-861-1212
Practice Address - Fax:901-861-1283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2203111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty