Provider Demographics
NPI:1255986931
Name:FASSAERT, MITCHELL GERARD (DC)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:GERARD
Last Name:FASSAERT
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 1:3220 E BASELINE RD STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-7110
Mailing Address - Country:US
Mailing Address - Phone:602-437-2225
Mailing Address - Fax:602-437-1309
Practice Address - Street 1:3220 E BASELINE RD STE 112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-7110
Practice Address - Country:US
Practice Address - Phone:602-437-2225
Practice Address - Fax:602-437-1309
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8827111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor