Provider Demographics
NPI:1457477663
Name:SMITH, MARK C (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1632 LINCOLN WAY E
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2918
Mailing Address - Country:US
Mailing Address - Phone:574-256-2635
Mailing Address - Fax:574-256-0030
Practice Address - Street 1:1632 LINCOLN WAY E
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2918
Practice Address - Country:US
Practice Address - Phone:574-256-2635
Practice Address - Fax:574-256-0030
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001934A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor