Provider Demographics
NPI:1881624989
Name:WALLACE, BROOK STEPHEN (DC)
Entity type:Individual
Prefix:DR
First Name:BROOK
Middle Name:STEPHEN
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 1:1000 N MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2056
Mailing Address - Country:US
Mailing Address - Phone:919-577-0660
Mailing Address - Fax:919-577-2286
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2056
Practice Address - Country:US
Practice Address - Phone:919-577-0660
Practice Address - Fax:919-577-2286
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2625111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0836GOtherBCBS PROVIDER NUMBER
NC890836GMedicaid
NC0836GOtherBCBS PROVIDER NUMBER
NCU75945Medicare UPIN