Provider Demographics
NPI:1013087121
Name:WALLACE, WILLIAM R (DC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
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 1:139 MORRISTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BERNARDSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07924-2606
Mailing Address - Country:US
Mailing Address - Phone:908-221-0808
Mailing Address - Fax:908-221-9024
Practice Address - Street 1:139 MORRISTOWN RD
Practice Address - Street 2:
Practice Address - City:BERNARDSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07924-2606
Practice Address - Country:US
Practice Address - Phone:908-221-0808
Practice Address - Fax:908-221-9024
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1922111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ122148Medicare ID - Type Unspecified