Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | SO1780 | MD |
NPI | 1003866419 |
---|---|
Provider Name | Dr. Jeffrey Neil Wallace |
First Address | Westminster, MD 21157-6127 |
Second Address | Westminster, MD 21157-6127 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2006 |
Last Update Date | 08/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
228P | (02) | MD |