Provider Demographics
NPI:1588325260
Name:WALLACE, GARRETT GENE (DC)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:GENE
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 1:2515 CROSBY AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4553
Mailing Address - Country:US
Mailing Address - Phone:541-883-2225
Mailing Address - Fax:541-882-9388
Practice Address - Street 1:2515 CROSBY AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4553
Practice Address - Country:US
Practice Address - Phone:541-883-2225
Practice Address - Fax:541-882-9388
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13851111N00000X
ORPENDING111N00000X
OR6236111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty