Provider Demographics
NPI:1366732000
Name:DR KRISTIE WALLACE DC LLC
Entity type:Organization
Organization Name:DR KRISTIE WALLACE DC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-522-1115
Mailing Address - Street 1:703 BLADEN ST
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-4915
Mailing Address - Country:US
Mailing Address - Phone:843-522-1115
Mailing Address - Fax:843-522-1119
Practice Address - Street 1:703 BLADEN ST
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-4915
Practice Address - Country:US
Practice Address - Phone:843-522-1115
Practice Address - Fax:843-522-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty