MEDICARE: MOUNT SHASTA CHIROPRACTIC & WELLNESS

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	111N00000X	Chiropractor	DC022167	CA

General Provider Information

NPI Number	:	1255886503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT SHASTA CHIROPRACTIC & WELLNESS

Provider Business Mailing Address
First Line	:	1180 S MOUNT SHASTA BLVD
Second Line	:	SUITE C
City	:	MOUNT SHASTA
State	:	CA
Zip	:	96067-2764
Country	:	US
Telephone Number	:	530-926-1072
Fax Number	:

Provider Business Practice Location Address
First Line	:	1180 S MOUNT SHASTA BLVD
Second Line	:	SUITE C
City	:	MOUNT SHASTA
State	:	CA
Zip	:	96067-2764
Country	:	US
Telephone Number	:	530-926-1072
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. NATHAN SIVANANDA
Credential	:	DC
Telephone Number	:	530-926-1072

Provider Enumeration Date	:	08/16/2016
Last Update Date	:	08/16/2016

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