Provider Demographics
NPI:1083076889
Name:MARK WATERMAN CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:MARK WATERMAN CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:909-720-3609
Mailing Address - Street 1:3008 DEERBROOK ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1620
Mailing Address - Country:US
Mailing Address - Phone:909-720-3609
Mailing Address - Fax:
Practice Address - Street 1:2440 W ARROW RTE
Practice Address - Street 2:STE 5A
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-9449
Practice Address - Country:US
Practice Address - Phone:909-670-2225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty