Provider Demographics
NPI:1376660050
Name:MITTELSTAEDT CHIROPRACTIC INC
Entity Type:Organization
Organization Name:MITTELSTAEDT CHIROPRACTIC INC
Other - Org Name:MITTELSTAEDT CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MITTELSTAEDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-452-7636
Mailing Address - Street 1:601 S RACE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6400
Mailing Address - Country:US
Mailing Address - Phone:360-452-7636
Mailing Address - Fax:360-457-4221
Practice Address - Street 1:601 S RACE ST
Practice Address - Street 2:SUITE C
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6400
Practice Address - Country:US
Practice Address - Phone:360-452-7636
Practice Address - Fax:360-457-4221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1365111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2040400Medicaid
WA2040400Medicaid
WAG8808875Medicare ID - Type Unspecified