Healthcare Provider Details

I. General information

NPI: 1003889148
Provider Name (Legal Business Name): DENVER R WALLACE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 SOUTH ELM STREET
BALD KNOB AR
72010-1177
US

IV. Provider business mailing address

430 SOUTH ELM STREET P.O. BOX 1177
BALD KNOB AR
72010-1177
US

V. Phone/Fax

Practice location:
  • Phone: 501-724-5614
  • Fax: 501-724-5614
Mailing address:
  • Phone: 501-724-5614
  • Fax: 501-724-5614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1319
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: