Provider Demographics
NPI:1235424078
Name:CHAN, MARY (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1101S WINCHESTER BLVD G183
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3903
Mailing Address - Country:US
Mailing Address - Phone:408-624-7543
Mailing Address - Fax:408-261-1915
Practice Address - Street 1:1101S WINCHESTER BLVD G183
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3903
Practice Address - Country:US
Practice Address - Phone:408-624-7543
Practice Address - Fax:408-261-1915
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31789111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor