MEDICARE: DR. JESSE BRYAN 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	10627	TX

General Provider Information

NPI Number	:	1871794495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSE BRYAN WALLACE D.C.

Provider Business Mailing Address
First Line	:	7410 BLANCO RD
Second Line	:	SUITE 400
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-4363
Country	:	US
Telephone Number	:	800-404-6050
Fax Number	:	210-477-7631

Provider Business Practice Location Address
First Line	:	7410 BLANCO RD
Second Line	:	SUITE 400
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-4363
Country	:	US
Telephone Number	:	800-404-6050
Fax Number	:	210-477-7631

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

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	08/21/2008

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