Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 2204 | SC |
NPI | 1013002260 |
---|---|
Provider Name | Dr. Wallace Harold Privette JR. |
First Address | Union, SC 29379-8609 |
Second Address | Union, SC 29379-8609 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2006 |
Last Update Date | 03/05/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
GCH198 | (05) | SC |