Provider Demographics
NPI:1649269788
Name:WALLACE, BRIAN F (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:F
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 1:306 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-1222
Mailing Address - Country:US
Mailing Address - Phone:814-849-5607
Mailing Address - Fax:
Practice Address - Street 1:306 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-1222
Practice Address - Country:US
Practice Address - Phone:814-849-5607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC 006829L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
815891OtherFIRST PRIORITY HEALTH
PA0016298480006Medicaid
PA75611OtherGEISINGER
PA710998Medicare ID - Type Unspecified
PA0016298480006Medicaid