Provider Demographics
NPI:1144541137
Name:MARK MATTOON DC LTD
Entity type:Organization
Organization Name:MARK MATTOON DC LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATTOON
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:775-882-1068
Mailing Address - Street 1:251 JEANELL DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-2158
Mailing Address - Country:US
Mailing Address - Phone:775-882-1068
Mailing Address - Fax:775-882-5131
Practice Address - Street 1:251 JEANELL DR
Practice Address - Street 2:SUITE 5
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-2158
Practice Address - Country:US
Practice Address - Phone:775-882-1068
Practice Address - Fax:775-882-5131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB00262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty