Provider Demographics
NPI:1144640632
Name:MASSAH, WALLACE K (DC)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:K
Last Name:MASSAH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 DUDLEY ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2573
Mailing Address - Country:US
Mailing Address - Phone:617-442-8600
Mailing Address - Fax:
Practice Address - Street 1:190 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2573
Practice Address - Country:US
Practice Address - Phone:617-442-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3444111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor