Individual
TYRONE D WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DC
Contact information
Practice address
263 KELLEY ST, STE 100, LAKE CITY, SC 29560-2450
(843) 394-8274
(843) 394-1604
Mailing address
263 KELLEY ST, STE 100, LAKE CITY, SC 29560-2450
(843) 394-8274
(843) 394-1604
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
1873
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
571012172
BC
SC
05
—
CH1873
—
SC
Enumeration date
05/09/2006
Last updated
12/07/2016
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