Provider Demographics
NPI:1992461123
Name:ROZEFORT, WALLACE ROSALES (DC)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:ROSALES
Last Name:ROZEFORT
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 1:100 RIVERFRONT DR APT 406
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4535
Mailing Address - Country:US
Mailing Address - Phone:850-848-7625
Mailing Address - Fax:
Practice Address - Street 1:20755 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5403
Practice Address - Country:US
Practice Address - Phone:248-595-8289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301401165111N00000X
FLCH13525111N00000X
KY271416111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor