Provider Demographics
NPI:1114030814
Name:HERTENSTEIN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HERTENSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:HERTENSTEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:222 15TH ST S
Mailing Address - Street 2:SUITE C
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405
Mailing Address - Country:US
Mailing Address - Phone:406-771-1222
Mailing Address - Fax:406-771-1225
Practice Address - Street 1:222 15TH ST S
Practice Address - Street 2:SUITE C
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-2459
Practice Address - Country:US
Practice Address - Phone:406-771-1222
Practice Address - Fax:406-771-1225
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT537111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0164398Medicaid
MT0164407Medicaid
MT40763Medicare UPIN
MT0164407Medicaid