Provider Demographics
NPI:1730205550
Name:VANDEVER, MARK ERIC (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ERIC
Last Name:VANDEVER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17224 N 43RD AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4025
Mailing Address - Country:US
Mailing Address - Phone:602-565-4402
Mailing Address - Fax:602-843-3787
Practice Address - Street 1:17224 N 43RD AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4025
Practice Address - Country:US
Practice Address - Phone:602-565-4402
Practice Address - Fax:602-843-3787
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5566111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5566OtherSTATE LICENSE NUMBER
AZ5566OtherSTATE LICENSE NUMBER