Provider Demographics
NPI:1487326344
Name:WETHERELL, SAMUEL (DC)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:WETHERELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4108 ELKHORN DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46062-6528
Mailing Address - Country:US
Mailing Address - Phone:217-251-9469
Mailing Address - Fax:
Practice Address - Street 1:8924 E 96TH ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9648
Practice Address - Country:US
Practice Address - Phone:317-588-9414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08003261A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08003261AOtherDC LICENSE NUMBER