Provider Demographics
NPI:1124188602
Name:MORDECAI, MICAH BONNETT (DC)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:BONNETT
Last Name:MORDECAI
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 1:200 W STATE HIGHWAY 6 STE 607
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-3984
Mailing Address - Country:US
Mailing Address - Phone:254-751-1606
Mailing Address - Fax:866-571-1622
Practice Address - Street 1:200 W STATE HIGHWAY 6 STE 607
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-3984
Practice Address - Country:US
Practice Address - Phone:254-751-1606
Practice Address - Fax:866-571-1622
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6236111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health