Provider Demographics
NPI:1336331339
Name:TRI-MED HEALTH & WELLNESS CENTER, PC
Entity Type:Organization
Organization Name:TRI-MED HEALTH & WELLNESS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MALLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-823-5555
Mailing Address - Street 1:PO BOX 2709
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52809-2709
Mailing Address - Country:US
Mailing Address - Phone:563-823-5555
Mailing Address - Fax:563-823-5556
Practice Address - Street 1:4915 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3063
Practice Address - Country:US
Practice Address - Phone:563-823-5555
Practice Address - Fax:563-823-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAT01112OtherUPIN
IA1192278Medicaid
IA1192278Medicaid