Provider Demographics
NPI:1932367539
Name:WALLACE, MARK RICHARD (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
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 1:9337 W 75TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204
Mailing Address - Country:US
Mailing Address - Phone:913-722-3200
Mailing Address - Fax:913-432-8392
Practice Address - Street 1:9337 W 75TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204
Practice Address - Country:US
Practice Address - Phone:913-722-3200
Practice Address - Fax:913-432-8392
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04348111N00000X
MO6478111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1063617918OtherNPI
KSKA1154001Medicare PIN