| Doctor Name: | TYRONE D WALLACE |
| NPI Number: | 1780633420 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | DC |
| License Number: | 1873 |
| Business Practice Address: | 263 Kelley St Ste 100 Lake City, SC - 295602450 |
| Business Phone Number: | 8433948274 |
| Business Fax Number: | 8433941604 |
| Mailing Address: | 263 Kelley St, Ste 100 LAKE CITY |
| State: | SC |
| Postal Code: | 295602450 |
| Phone Number: | 8433948274 |
| Fax Number: | 8433941604 |
| NPI Enumeration Date: | 05/09/2006 |
| NPI Last Update Date: | 06/20/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | 1873 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | SC |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |