=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932083482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALLACE BRAIN AND SPINE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2025
-----------------------------------------------------
Last Update Date | 08/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 BRICKERTON ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39701-3608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-251-2195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 518 GREENSBORO ST
-----------------------------------------------------
City | STARKVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39759-2805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-251-2195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD CHIROPRACTOR
-----------------------------------------------------
Name | DR. CLARA BAILEY WALLACE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 662-251-2195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------