Provider Demographics
NPI:1871133272
Name:SUTTER, MITCHELL WADE (DC)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:WADE
Last Name:SUTTER
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 1:156 COUNTY ROAD 313
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MO
Mailing Address - Zip Code:63471-2056
Mailing Address - Country:US
Mailing Address - Phone:217-430-4476
Mailing Address - Fax:
Practice Address - Street 1:156 COUNTY ROAD 313
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MO
Practice Address - Zip Code:63471-2056
Practice Address - Country:US
Practice Address - Phone:217-430-4476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013497111N00000X
MO2020015015111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor