Provider Demographics
NPI:1023132644
Name:WALLACE, ROBERT S (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
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 1:7 CENTRE DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:MONROE
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-1565
Mailing Address - Country:US
Mailing Address - Phone:609-662-4714
Mailing Address - Fax:609-662-4708
Practice Address - Street 1:7 CENTRE DR
Practice Address - Street 2:SUITE 10
Practice Address - City:MONROE
Practice Address - State:NJ
Practice Address - Zip Code:08831-1565
Practice Address - Country:US
Practice Address - Phone:609-662-4714
Practice Address - Fax:609-662-4708
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010144111N00000X, 111N00000X
NJ38MC00701200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA173429OtherMEDICARE PTAN
NJG300000110OtherMEDICARE PTAN
NJG300000110OtherMEDICARE PTAN