Basic Information
| Provider Information | |||||||||
| NPI: | 1457424467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3530 S VAL VISTA DR | ||||||||
| Address2: | B105 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808994333 | ||||||||
| FaxNumber: | 4808997219 | ||||||||
| Practice Location | |||||||||
| Address1: | 3530 S VAL VISTA DR | ||||||||
| Address2: | B105 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808994333 | ||||||||
| FaxNumber: | 4808997219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 038-009141 | IL | N | Chiropractic Providers | Chiropractor | 111N00000X | 8330 | AZ | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 05527512 | 01 | IL | BCBS | OTHER |