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General NPI Number Information
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NPI Number | 1427209055
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Entity Type | Organization
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Legal Business Name | SCOTT M WALLACE LTD
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Dates
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Enumeration Date | 10/01/2008
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Last Update Date | 10/01/2008
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Provider Practice Location Address
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Address Line | 8960 W CHEYENNE AVE SUITE 110
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City | LAS VEGAS
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State | NV
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Zip | 89129-8929
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Country | US
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Telephone | 702-474-6996
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Fax | 702-655-4389
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Provider Business Mailing Address
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Address Line | 8960 W CHEYENNE AVE SUITE 110
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City | LAS VEGAS
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State | NV
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Zip | 89129-8929
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Country | US
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Telephone | 702-474-6996
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Fax | 702-655-4389
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MICHELLE DIANE CHENEY
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Credential |
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Telephone | 702-474-6996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | B383
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License Number State | NV
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