Provider Demographics
NPI:1437159746
Name:THERIAULT, MARK (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:THERIAULT
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:PO BOX 1375
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-2004
Mailing Address - Country:US
Mailing Address - Phone:704-489-2273
Mailing Address - Fax:704-489-2274
Practice Address - Street 1:1895 N HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-8642
Practice Address - Country:US
Practice Address - Phone:704-489-2273
Practice Address - Fax:704-489-2274
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2346111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor