Provider Demographics
NPI:1154365708
Name:ROSS, WALLACE CHARLES (DC)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:CHARLES
Last Name:ROSS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1432
Mailing Address - Country:US
Mailing Address - Phone:248-321-5405
Mailing Address - Fax:810-797-3615
Practice Address - Street 1:208 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1432
Practice Address - Country:US
Practice Address - Phone:248-321-5405
Practice Address - Fax:810-797-3615
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT32778Medicare UPIN