Provider Demographics
NPI:1205835154
Name:WALLACE, JOHN R (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
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 1:994 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-3522
Mailing Address - Country:US
Mailing Address - Phone:231-755-3333
Mailing Address - Fax:231-755-5891
Practice Address - Street 1:994 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-3522
Practice Address - Country:US
Practice Address - Phone:231-755-3333
Practice Address - Fax:231-755-5891
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJW004751111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF15031Medicare ID - Type Unspecified
OF15031Medicare UPIN