Provider Demographics
NPI:1568527034
Name:MULLEN, WESLEY S JR (DC)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:S
Last Name:MULLEN
Suffix:JR
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 1:34 N MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1117
Mailing Address - Country:US
Mailing Address - Phone:570-474-5042
Mailing Address - Fax:570-474-5222
Practice Address - Street 1:34 N MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN TOP
Practice Address - State:PA
Practice Address - Zip Code:18707-1117
Practice Address - Country:US
Practice Address - Phone:570-474-5042
Practice Address - Fax:570-474-5222
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001393L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA350925065OtherPALMETTO RAILROAD MEDICAR
PA0006143120001Medicaid
PA0006143120001Medicaid
PAMU115663Medicare ID - Type Unspecified