Provider Demographics
NPI:1760755912
Name:MELLON CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:MELLON CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MELLON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:301-831-5444
Mailing Address - Street 1:13002 PENN SHOP RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-4517
Mailing Address - Country:US
Mailing Address - Phone:301-831-5444
Mailing Address - Fax:301-829-5729
Practice Address - Street 1:13002 PENN SHOP RD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-4517
Practice Address - Country:US
Practice Address - Phone:301-831-5444
Practice Address - Fax:301-829-5729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01555111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1679665624OtherNPI TYPE 1
MD1679665624OtherNPI TYPE 1