Provider Demographics
NPI:1366501447
Name:MOUNTAIN STATE CHIROPRACTIC
Entity Type:Organization
Organization Name:MOUNTAIN STATE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:304-583-6400
Mailing Address - Street 1:PO BOX 664
Mailing Address - Street 2:
Mailing Address - City:MAN
Mailing Address - State:WV
Mailing Address - Zip Code:25635-0664
Mailing Address - Country:US
Mailing Address - Phone:304-583-6400
Mailing Address - Fax:
Practice Address - Street 1:310 MARKET ST
Practice Address - Street 2:
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635-1321
Practice Address - Country:US
Practice Address - Phone:304-583-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV823111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0208726000Medicaid
WV=========OtherPEIA