MEDICARE: DR. JEFFREY DAVID 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	2301008560	MI

General Provider Information

NPI Number	:	1679563928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY DAVID WALLACE D.C.

Provider Business Mailing Address
First Line	:	820 CHARLEVOIX DR
Second Line	:	SUITE 210
City	:	GRAND LEDGE
State	:	MI
Zip	:	48837-8188
Country	:	US
Telephone Number	:	517-622-2273
Fax Number	:	517-622-2223

Provider Business Practice Location Address
First Line	:	820 CHARLEVOIX DR
Second Line	:	SUITE 210
City	:	GRAND LEDGE
State	:	MI
Zip	:	48837-8188
Country	:	US
Telephone Number	:	517-622-2273
Fax Number	:	517-622-2223

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

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	07/08/2007

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