Provider Demographics
NPI:1083726632
Name:CHILDRESS, MARK CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHARLES
Last Name:CHILDRESS
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 1:15283 W 147TH DR
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-5002
Mailing Address - Country:US
Mailing Address - Phone:913-744-2973
Mailing Address - Fax:913-345-9259
Practice Address - Street 1:11960 W 119TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-2216
Practice Address - Country:US
Practice Address - Phone:913-744-2973
Practice Address - Fax:913-245-9259
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4944111N00000X
MO2006012360111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST71E345Medicare ID - Type Unspecified
KSV07985Medicare UPIN