Provider Demographics
NPI:1134194897
Name:MELLIN, TIMOTHY PATRICK (DC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PATRICK
Last Name:MELLIN
Suffix:
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 1:700 BITNER RD
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5489
Mailing Address - Country:US
Mailing Address - Phone:435-615-2261
Mailing Address - Fax:435-615-2754
Practice Address - Street 1:700 BITNER RD
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5489
Practice Address - Country:US
Practice Address - Phone:435-615-2261
Practice Address - Fax:435-615-2754
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT48595611202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00005589401Medicaid
TX00005589401Medicaid