Provider Demographics
NPI:1114993672
Name:BREAULT, MARK E (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:BREAULT
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 1:127 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CONCORDIA
Mailing Address - State:KS
Mailing Address - Zip Code:66901-2902
Mailing Address - Country:US
Mailing Address - Phone:785-243-1454
Mailing Address - Fax:785-243-1232
Practice Address - Street 1:127 E 6TH ST
Practice Address - Street 2:
Practice Address - City:CONCORDIA
Practice Address - State:KS
Practice Address - Zip Code:66901-2902
Practice Address - Country:US
Practice Address - Phone:785-243-1454
Practice Address - Fax:785-243-1232
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSC3507111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS005439Medicare ID - Type Unspecified