Provider Demographics
NPI:1871602987
Name:MELLOR CHIROPRACTIC CLINIC P.A.
Entity type:Organization
Organization Name:MELLOR CHIROPRACTIC CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MELLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-356-6009
Mailing Address - Street 1:54 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2047
Mailing Address - Country:US
Mailing Address - Phone:208-356-6009
Mailing Address - Fax:
Practice Address - Street 1:54 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2047
Practice Address - Country:US
Practice Address - Phone:208-356-6009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC343320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1670873Medicare UPIN