Provider Demographics
NPI:1770116865
Name:MILES SPETH, MALLORY (DC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MILES SPETH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:COBB
Mailing Address - State:WI
Mailing Address - Zip Code:53526-8501
Mailing Address - Country:US
Mailing Address - Phone:608-292-9440
Mailing Address - Fax:
Practice Address - Street 1:109 DIVISION ST
Practice Address - Street 2:
Practice Address - City:COBB
Practice Address - State:WI
Practice Address - Zip Code:53526-8501
Practice Address - Country:US
Practice Address - Phone:608-723-7723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5482-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor