Healthcare Provider Details

I. General information

NPI: 1053583450
Provider Name (Legal Business Name): MOUNTAINSIDE WELLNESS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16515 S 40TH ST STE 129
PHOENIX AZ
85048-0560
US

IV. Provider business mailing address

4909 E CHANDLER BLVD STE 502
PHOENIX AZ
85048-0863
US

V. Phone/Fax

Practice location:
  • Phone: 480-940-7444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7077
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number3751
License Number StateAZ

VIII. Authorized Official

Name: DR. JOHN SCOTT METTHAM
Title or Position: VICE PRESIDENT
Credential: D.C., P.T.
Phone: 480-940-7444