Provider Demographics
NPI:1871847749
Name:MARY WALLACE DC, PLLC
Entity type:Organization
Organization Name:MARY WALLACE DC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:603-721-2162
Mailing Address - Street 1:434 LUNA BELLA LANE
Mailing Address - Street 2:APT 230
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168
Mailing Address - Country:US
Mailing Address - Phone:603-721-2162
Mailing Address - Fax:
Practice Address - Street 1:292 STATE ROUTE 101
Practice Address - Street 2:UNIT K2
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031
Practice Address - Country:US
Practice Address - Phone:603-721-2162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-31
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH903111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty