Provider Demographics
NPI:1942241096
Name:WALLACE, MARK ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
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 1:2140 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:901-961-1283
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010621111N00000X
TNDC0000002203111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor