Provider Demographics
NPI:1851499388
Name:WALLIS, MATTHEW C (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:C
Last Name:WALLIS
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 1:2725 JAMES SANDERS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-8401
Mailing Address - Country:US
Mailing Address - Phone:270-554-5114
Mailing Address - Fax:270-554-5021
Practice Address - Street 1:2725 JAMES SANDERS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-8401
Practice Address - Country:US
Practice Address - Phone:270-554-5114
Practice Address - Fax:270-554-5021
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4456111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY611375366OtherTAX ID
KYU71886Medicare UPIN
KY611375366OtherTAX ID
0043601Medicare PIN