Provider Demographics
NPI:1053583450
Name:MOUNTAINSIDE WELLNESS CENTER INC
Entity type:Organization
Organization Name:MOUNTAINSIDE WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:METTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC, PT
Authorized Official - Phone:480-940-7444
Mailing Address - Street 1:4909 E CHANDLER BLVD STE 502
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16515 S 40TH ST STE 129
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0560
Practice Address - Country:US
Practice Address - Phone:480-940-7444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7077111N00000X
AZ3751208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty