Provider Demographics
NPI:1083839179
Name:SURPRENANT, MARC JASON (DC)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:JASON
Last Name:SURPRENANT
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 1:7245 PINEVILLE MATTHEWS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-6163
Mailing Address - Country:US
Mailing Address - Phone:704-540-0055
Mailing Address - Fax:704-540-0102
Practice Address - Street 1:7245 PINEVILLE MATTHEWS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-6163
Practice Address - Country:US
Practice Address - Phone:704-540-0055
Practice Address - Fax:704-540-0102
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC3119111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU82777Medicare UPIN
NC2455705AMedicare ID - Type Unspecified