Provider Demographics
NPI:1861516890
Name:BOTHA, MARK L (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:BOTHA
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 1:75 S MADISON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-3037
Mailing Address - Country:US
Mailing Address - Phone:303-321-2252
Mailing Address - Fax:
Practice Address - Street 1:75 S MADISON ST STE 200
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-3037
Practice Address - Country:US
Practice Address - Phone:303-321-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5871111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor