=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255359576
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK CHRISTOPHER WELLER D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49100 PONTIAC TRL
-----------------------------------------------------
City | WIXOM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48393-2569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-669-1108
-----------------------------------------------------
Fax | 248-669-2552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49100 PONTIAC TRAIL
-----------------------------------------------------
City | WIXOM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-669-1108
-----------------------------------------------------
Fax | 248-669-2552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301002986
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------