Provider Demographics
NPI:1215014139
Name:MAVIS, MARC KARL (DC)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:KARL
Last Name:MAVIS
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 1:2550 NILES RD
Mailing Address - Street 2:MAVIS CHIROPRACTIC CENTER
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-429-5727
Mailing Address - Fax:269-429-5766
Practice Address - Street 1:2550 NILES RD
Practice Address - Street 2:
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-429-5727
Practice Address - Fax:269-429-5766
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004976111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950A150130OtherBCBS MI
MI2301004976OtherMI LICENSE
T32618Medicare UPIN
OA15013Medicare ID - Type Unspecified