Healthcare Provider Details

I. General information

NPI: 1063438307
Provider Name (Legal Business Name): TIMOTHY MARK WALLACE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4357 PHELAN RD
PHELAN CA
92371-7675
US

IV. Provider business mailing address

4357 PHELAN RD
PHELAN CA
92371-7675
US

V. Phone/Fax

Practice location:
  • Phone: 760-868-4481
  • Fax: 760-868-1879
Mailing address:
  • Phone: 760-868-4481
  • Fax: 760-868-1879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number23400
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: