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NPI Code Detail

MEDICARE: MALLORY NICOLE WALES D.C.

MEDICARE: MALLORY NICOLE WALES 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
1111N00000XChiropractor08002702AIN
2111N00000XChiropractor2301010995MI

General Provider Information

NPI Number : 1457691594
Entity Type Code : Individual
Provider Name (Legal Business Name) : MALLORY NICOLE WALES D.C.
Provider Business Mailing Address
First Line : 1637 HUFFMAN BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46808-2203
Country : US
Telephone Number : 269-207-9090
Fax Number :
Provider Business Practice Location Address
First Line : 26300 WOODWARD AVE
Second Line :
City : ROYAL OAK
State : MI
Zip : 48067-0917
Country : US
Telephone Number : 248-546-2110
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/27/2013
Last Update Date : 08/27/2021

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