MEDICARE: WALLACE CHIROPRACTIC CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor		MI

General Provider Information

NPI Number	:	1023068327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLACE CHIROPRACTIC CENTER

Provider Business Mailing Address
First Line	:	994 W BROADWAY AVE
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-3522
Country	:	US
Telephone Number	:	231-755-3333
Fax Number	:	231-755-5891

Provider Business Practice Location Address
First Line	:	994 W BROADWAY AVE
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-3522
Country	:	US
Telephone Number	:	231-755-3333
Fax Number	:	231-755-5891

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN R. WALLACE
Credential	:	D.C.
Telephone Number	:	231-755-3333

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	07/21/2022

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