Provider Demographics
NPI:1902428071
Name:WALLACE, KALI (DC)
Entity Type:Individual
Prefix:
First Name:KALI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-3328
Mailing Address - Country:US
Mailing Address - Phone:432-559-5732
Mailing Address - Fax:
Practice Address - Street 1:618 SW 3RD ST STE H
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-2277
Practice Address - Country:US
Practice Address - Phone:816-287-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020012757111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner