Provider Demographics
NPI:1144540923
Name:TILLEY, MARK CHRISTIAN (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHRISTIAN
Last Name:TILLEY
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 1:1234 W PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4017
Mailing Address - Country:US
Mailing Address - Phone:575-885-5808
Mailing Address - Fax:
Practice Address - Street 1:1234 W PIERCE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-4017
Practice Address - Country:US
Practice Address - Phone:575-885-5808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1816111N00000X
CO6524111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor