Provider Demographics
NPI:1619443819
Name:MISTOLER, MIRANDA (DC)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
Last Name:MISTOLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3195 LEAPHART RD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3001
Mailing Address - Country:US
Mailing Address - Phone:803-507-9555
Mailing Address - Fax:
Practice Address - Street 1:3195 LEAPHART RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3001
Practice Address - Country:US
Practice Address - Phone:803-507-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4325111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor