Provider Demographics
NPI:1487991683
Name:WALLACE, ROBERT J (LAC, LMT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 W MONTROSE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613
Mailing Address - Country:US
Mailing Address - Phone:773-248-4489
Mailing Address - Fax:
Practice Address - Street 1:1619 W MONTROSE
Practice Address - Street 2:CHICAGO HOLISTIC MEDICINE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-248-4489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000640171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist