MEDICARE: DR. MARY 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	903	NH

General Provider Information

NPI Number	:	1336497460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY WALLACE D.C.

Provider Business Mailing Address
First Line	:	6093 SABAL CREEK BLVD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-7139
Country	:	US
Telephone Number	:	603-721-2162
Fax Number	:

Provider Business Practice Location Address
First Line	:	292 STATE ROUTE 101 UNIT K2
Second Line	:
City	:	AMHERST
State	:	NH
Zip	:	03031-1730
Country	:	US
Telephone Number	:	603-721-2162
Fax Number	:

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

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	08/22/2025

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Directions to “ DR. MARY WALLACE D.C.” Practice Location

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