Individual
DR. HARRY L. WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.C.
Contact information
Practice address
2001 52ND AVE, SUITE 1, MOLINE, IL 61265-6368
(309) 764-4901
Mailing address
2001 52ND AVE, SUITE 1, MOLINE, IL 61265-6368
(309) 764-4901
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
04667
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
038003364
—
IL
01
—
323290
BLUE CROSS BLUE SHIELD IL
IL
01
—
527080
MEDICARE
IL
Enumeration date
03/23/2006
Last updated
03/18/2014
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