MEDICARE: MOUNTAINSIDE WELLNESS CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	3751	AZ
2	111N00000X	Chiropractor	7077	AZ

General Provider Information

NPI Number	:	1053583450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAINSIDE WELLNESS CENTER INC

Provider Business Mailing Address
First Line	:	4909 E CHANDLER BLVD STE 502
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-0863
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16515 S 40TH ST STE 129
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-0560
Country	:	US
Telephone Number	:	480-940-7444
Fax Number	:

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

Provider Enumeration Date	:	03/26/2008
Last Update Date	:	11/08/2023

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Directions to “MOUNTAINSIDE WELLNESS CENTER INC ” Practice Location

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