Healthcare Provider Details

I. General information

NPI: 1801245295
Provider Name (Legal Business Name): WALLACE CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 S. ELM ST
BALD KNOB AR
72010
US

IV. Provider business mailing address

PO BOX 1177
BALD KNOB AR
72010-1177
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MEGAN M PEARSON
Title or Position: OFFICE MANAGER/CREDENTIALING
Credential: LPN
Phone: 501-724-5614