Provider Demographics
NPI:1295775161
Name:WALLACE, DARIN WADE (DC)
Entity type:Individual
Prefix:MR
First Name:DARIN
Middle Name:WADE
Last Name:WALLACE
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 1:1105 N BENJAMIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46173-1356
Mailing Address - Country:US
Mailing Address - Phone:765-932-5600
Mailing Address - Fax:765-932-5530
Practice Address - Street 1:1520 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173
Practice Address - Country:US
Practice Address - Phone:765-932-5600
Practice Address - Fax:765-932-5530
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001985A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200369100AMedicaid
IN204270Medicare PIN
IN200369100AMedicaid
INM400058456Medicare PIN