Provider Demographics
NPI:1386732584
Name:WALLACE, TERRANCE MARK (DC)
Entity type:Individual
Prefix:DR
First Name:TERRANCE
Middle Name:MARK
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-0009
Mailing Address - Country:US
Mailing Address - Phone:715-386-7700
Mailing Address - Fax:
Practice Address - Street 1:411 COUNTY ROAD UU
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7576
Practice Address - Country:US
Practice Address - Phone:715-386-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI27F65WAOtherBCBS
WI44-40146OtherMEDICA
WI71907OtherHEALTH PARTNERS
WI392000316019OtherBLUE CROSS WI
WI38765600Medicaid
WI0000350049822Medicare ID - Type Unspecified
WIT63599Medicare UPIN