Provider Demographics
NPI:1083764062
Name:FANDEL, MARK CALVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CALVIN
Last Name:FANDEL
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:PO BOX 1255
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29578-1255
Mailing Address - Country:US
Mailing Address - Phone:843-626-9340
Mailing Address - Fax:843-626-9540
Practice Address - Street 1:505 18TH AVE N STE B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3535
Practice Address - Country:US
Practice Address - Phone:843-626-9340
Practice Address - Fax:843-626-9540
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2264111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2264Medicaid