Active NPI
Timothy Mark Wallace, D.C.
- Chiropractor
- Phelan, CA
National Provider Identifier
1063438307
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Chiropractor
- License
- 23400
- Practice address
- 4357 Phelan Rd
Phelan, CA 92371-7675 - Phone
- (760) 868-4481
- Fax
- (760) 868-1879
- NPI assigned
- Jul 13, 2006
- Last updated
- Jan 27, 2012
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Chiropractor | 111N00000X | 23400 | CA | Primary |
Addresses
Primary practice location
4357 Phelan Rd
Phelan, CA 92371-7675
Mailing address
4357 Phelan Rd
Phelan, CA 92371-7675
Phone (760) 868-4481
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20120329000730 | CA | Practitioner - Chiropractic | 8628238573 | Practice locations: Phelan, CA |
Care Compare profile
Medicare Care Compare- Specialty
- Chiropractic
- Education
- Los Angeles College of Chiropractic, 1999
- Medicare assignment
- May accept Medicare assignment
Practice addresses (Care Compare)
4357 Phelan Rd
Phelan, CA 92371-7675
Phone (760) 868-4481
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 23400 | CA | MD | Critical Care Certified Respiratory Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152748800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1327622400000",
"number": "1063438307",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4357 PHELAN RD",
"city": "PHELAN",
"state": "CA",
"postal_code": "923717675",
"telephone_number": "760-868-4481",
"fax_number": "760-868-1879"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4357 PHELAN RD",
"city": "PHELAN",
"state": "CA",
"postal_code": "923717675",
"telephone_number": "760-868-4481",
"fax_number": "760-868-1879"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "TIMOTHY",
"middle_name": "MARK",
"name_prefix": "Dr.",
"credential": "D.C.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-07-13",
"last_updated": "2012-01-27",
"status": "A"
},
"taxonomies": [
{
"code": "111N00000X",
"taxonomy_group": "",
"desc": "Chiropractor",
"state": "CA",
"license": "23400",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Phelan, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.