Healthcare Provider Details

I. General information

NPI: 1730215260
Provider Name (Legal Business Name): WALLACE FAMILY CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 E STEGER RD
CRETE IL
60417-1362
US

IV. Provider business mailing address

1020 E STEGER RD
CRETE IL
60417-1362
US

V. Phone/Fax

Practice location:
  • Phone: 708-672-2100
  • Fax: 708-672-2121
Mailing address:
  • Phone: 708-672-2100
  • Fax: 708-672-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. SARA ANNE WALLACE
Title or Position: PRESIDENT
Credential: D.C.
Phone: 708-672-2100