Healthcare Provider Details

I. General information

NPI: 1902428071
Provider Name (Legal Business Name): KALI WALLACE DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 SW 3RD ST STE H
LEES SUMMIT MO
64063-2277
US

IV. Provider business mailing address

3304 GATEWAY DR
INDEPENDENCE MO
64057-3328
US

V. Phone/Fax

Practice location:
  • Phone: 816-287-4044
  • Fax:
Mailing address:
  • Phone: 432-559-5732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number2020012757
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: