Provider Demographics
NPI:1255886503
Name:MOUNT SHASTA CHIROPRACTIC & WELLNESS
Entity type:Organization
Organization Name:MOUNT SHASTA CHIROPRACTIC & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVANANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:530-926-1072
Mailing Address - Street 1:1180 S MOUNT SHASTA BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2764
Mailing Address - Country:US
Mailing Address - Phone:530-926-1072
Mailing Address - Fax:
Practice Address - Street 1:1180 S MOUNT SHASTA BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2764
Practice Address - Country:US
Practice Address - Phone:530-926-1072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC022167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty