Provider Demographics
NPI:1790925063
Name:MOUNTFORD, EVAN JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:JOHN
Last Name:MOUNTFORD
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 1:6205 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-8930
Mailing Address - Country:US
Mailing Address - Phone:916-652-7373
Mailing Address - Fax:
Practice Address - Street 1:6205 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:LOOMIS
Practice Address - State:CA
Practice Address - Zip Code:95650-8930
Practice Address - Country:US
Practice Address - Phone:916-652-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-31150111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor