Provider Demographics
NPI:1033299359
Name:BANASIAK, MARK S (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:BANASIAK
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 1:27555 YNEZ RD STE 350
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4688
Mailing Address - Country:US
Mailing Address - Phone:951-587-2225
Mailing Address - Fax:951-676-5158
Practice Address - Street 1:27555 YNEZ RD STE 350
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4688
Practice Address - Country:US
Practice Address - Phone:951-587-2225
Practice Address - Fax:951-365-0027
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23625111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0236251OtherMEDICARE ID
ZZZ63647YOtherBLUE SHIELD
ZZZ63647YOtherBLUE SHIELD