Provider Demographics
NPI:1225147309
Name:MELLOR, STEPHEN PAUL (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PAUL
Last Name:MELLOR
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 1:54 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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1670873Medicare UPIN