MEDICARE: WALLIS CHIROPRACTIC LLC

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	CH10990	FL

General Provider Information

NPI Number	:	1962890533
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLIS CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	6309 CORPORATE CT STE 110
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-3539
Country	:	US
Telephone Number	:	239-433-1011
Fax Number	:	239-433-3737

Provider Business Practice Location Address
First Line	:	6309 CORPORATE CT STE 110
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-3539
Country	:	US
Telephone Number	:	239-433-1011
Fax Number	:	239-433-3737

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. KELLY JEAN WALLIS
Credential	:	D.C.
Telephone Number	:	239-433-1011

Provider Enumeration Date	:	01/05/2015
Last Update Date	:	01/05/2015

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