Provider Demographics
NPI:1255388971
Name:MIKE MASON CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:MIKE MASON CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:304-842-4202
Mailing Address - Street 1:529 E. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330
Mailing Address - Country:US
Mailing Address - Phone:304-842-4202
Mailing Address - Fax:304-842-6480
Practice Address - Street 1:529 E. MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-842-4202
Practice Address - Fax:304-842-6480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001713619OtherMTN STATE BCBS PAY-TO
WVPENDINGMedicaid
WVPENDINGMedicaid