Healthcare Provider Details

I. General information

NPI: 1639753239
Provider Name (Legal Business Name): SHANE EDWARD WALLACE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 WAMPLERS LAKE RD
BROOKLYN MI
49230-9503
US

IV. Provider business mailing address

9909 WAMPLERS LAKE RD
BROOKLYN MI
49230-9503
US

V. Phone/Fax

Practice location:
  • Phone: 517-592-8208
  • Fax:
Mailing address:
  • Phone: 517-592-8208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301011096
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: