Healthcare Provider Details

I. General information

NPI: 1255359576
Provider Name (Legal Business Name): MARK CHRISTOPHER WELLER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49100 PONTIAC TRL
WIXOM MI
48393-2569
US

IV. Provider business mailing address

49100 PONTIAC TRAIL
WIXOM MI
48393
US

V. Phone/Fax

Practice location:
  • Phone: 248-669-1108
  • Fax: 248-669-2552
Mailing address:
  • Phone: 248-669-1108
  • Fax: 248-669-2552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301002986
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: