Healthcare Provider Details

I. General information

NPI: 1376660050
Provider Name (Legal Business Name): MITTELSTAEDT CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 12/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S RACE ST SUITE C
PORT ANGELES WA
98362-6400
US

IV. Provider business mailing address

601 S RACE ST SUITE C
PORT ANGELES WA
98362-6400
US

V. Phone/Fax

Practice location:
  • Phone: 360-452-7636
  • Fax: 360-457-4221
Mailing address:
  • Phone: 360-452-7636
  • Fax: 360-457-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1365
License Number StateWA

VIII. Authorized Official

Name: DR. BRIAN WILLIAM MITTELSTAEDT
Title or Position: DOCTOR-OWNER
Credential: D.C.
Phone: 360-452-7636