Provider Demographics
NPI:1447496922
Name:WALLACE, DARRELL Y (LIC AC)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:Y
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-3638
Mailing Address - Country:US
Mailing Address - Phone:617-719-4592
Mailing Address - Fax:
Practice Address - Street 1:THE CONCORD CLINIC
Practice Address - Street 2:56 WINTHROP STREET
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742
Practice Address - Country:US
Practice Address - Phone:617-719-4592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203604171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist