Provider Demographics
NPI:1790900744
Name:MELLON CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:MELLON CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN,OWNER,PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MELLON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:906-774-2488
Mailing Address - Street 1:208 E HUGHITT ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-2910
Mailing Address - Country:US
Mailing Address - Phone:906-774-2488
Mailing Address - Fax:906-774-2307
Practice Address - Street 1:208 E HUGHITT ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-2910
Practice Address - Country:US
Practice Address - Phone:906-774-2488
Practice Address - Fax:906-774-2307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004916111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950B210770OtherBLUE CROSS BLUE SHIELD
MI950B210770OtherBLUE CROSS BLUE SHIELD