Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NX0800X | Chiropractor Orthopedic Specialist | 12087 | CA |
NPI | 1013124908 |
---|---|
Provider Name | Dr. James Doran Wallace |
First Address | Sacramento, CA 95826-1923 |
Second Address | Roseville, CA 95661-3061 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 16/05/2009 |