1871847749 NPI number — MARY WALLACE, DC, P.L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871847749 NPI number — MARY WALLACE, DC, P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY WALLACE, DC, P.L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BACK FOR MORE CHIROPRACTIC HEALTH AND REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871847749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 BEDFORD CENTER RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03110-5442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 BEDFORD CENTER RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03110-5442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-320-2519
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
603-320-2519

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  903 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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