MEDICARE: DR. JOHN R WALLACE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	JW004751	MI

General Provider Information

NPI Number	:	1205835154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN R WALLACE D.C.

Provider Business Mailing Address
First Line	:	994 W BROADWAY AVE
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-3522
Country	:	US
Telephone Number	:	231-755-3333
Fax Number	:	231-755-5891

Provider Business Practice Location Address
First Line	:	994 W BROADWAY AVE
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-3522
Country	:	US
Telephone Number	:	231-755-3333
Fax Number	:	231-755-5891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	11/29/2011

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Directions to “ DR. JOHN R WALLACE D.C.” Practice Location

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