Provider Demographics
NPI:1083826176
Name:AUDIA, MARY K (DC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:AUDIA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2771 OAKDALE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-9747
Mailing Address - Country:US
Mailing Address - Phone:319-853-8592
Mailing Address - Fax:
Practice Address - Street 1:2771 OAKDALE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-9747
Practice Address - Country:US
Practice Address - Phone:319-853-8592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06826111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00758NMedicare ID - Type Unspecified