Provider Demographics
NPI:1326268269
Name:VINICK, MARK LEWIS (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEWIS
Last Name:VINICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1860 S ELENA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5706
Mailing Address - Country:US
Mailing Address - Phone:310-375-4325
Mailing Address - Fax:310-373-9225
Practice Address - Street 1:1860 S ELENA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5706
Practice Address - Country:US
Practice Address - Phone:310-375-4325
Practice Address - Fax:310-373-9225
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18993111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU21183Medicare UPIN