1154467934 NPI number — DR WALTER J MELLGREN JR DC PA

Table of content: (NPI 1154467934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154467934 NPI number — DR WALTER J MELLGREN JR DC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR WALTER J MELLGREN JR DC PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MELLGREN CHIROPRACTIC CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154467934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 475
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76691-0475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-826-3737
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 N REAGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76691-1446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-826-3737
Provider Business Practice Location Address Fax Number:
254-826-3769
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MELLGREN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
AARON
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
254-826-3737

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00L71L . This is a "BLUE CROSS BLUESHIELD OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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