MEDICARE: TYRONE D WALLACE DC

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	1873	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	571012172	OTHER	SC	BC

General Provider Information

NPI Number	:	1780633420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRONE D WALLACE DC

Provider Business Mailing Address
First Line	:	263 KELLEY ST
Second Line	:	STE 100
City	:	LAKE CITY
State	:	SC
Zip	:	29560-2450
Country	:	US
Telephone Number	:	843-394-8274
Fax Number	:	843-394-1604

Provider Business Practice Location Address
First Line	:	263 KELLEY ST
Second Line	:	STE 100
City	:	LAKE CITY
State	:	SC
Zip	:	29560-2450
Country	:	US
Telephone Number	:	843-394-8274
Fax Number	:	843-394-1604

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

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	12/07/2016

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Directions to “ TYRONE D WALLACE DC” Practice Location

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