Provider Demographics
NPI:1952706673
Name:WALLACE, KENNETH (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
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 1:119 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3377
Mailing Address - Country:US
Mailing Address - Phone:321-226-1115
Mailing Address - Fax:321-251-6091
Practice Address - Street 1:119 S PARK AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3377
Practice Address - Country:US
Practice Address - Phone:321-226-1115
Practice Address - Fax:321-251-6091
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 11302111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor