Provider Demographics
NPI:1326531070
Name:VICK, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:VICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 MOUNT VERNON AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-1342
Mailing Address - Country:US
Mailing Address - Phone:703-489-0754
Mailing Address - Fax:
Practice Address - Street 1:2016 MOUNT VERNON AVE STE 209
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22301-1342
Practice Address - Country:US
Practice Address - Phone:703-489-0754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator