Healthcare Provider Details

I. General information

NPI: 1104883164
Provider Name (Legal Business Name): TIMOTHY JAMES MUNDERLOH DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E CEDAR AVE STE 80
FLAGSTAFF AZ
86004
US

IV. Provider business mailing address

1500 E CEDAR AVE STE 80
FLAGSTAFF AZ
86004
US

V. Phone/Fax

Practice location:
  • Phone: 928-556-0707
  • Fax: 928-522-8462
Mailing address:
  • Phone: 928-556-0707
  • Fax: 928-522-8462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5935
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number1058
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: