Provider Demographics
NPI:1477980001
Name:NEELY, MARK DAVID
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:NEELY
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 1:65 PINE RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:MARS HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 ATHLETIC STREET
Practice Address - Street 2:
Practice Address - City:MARS HILL
Practice Address - State:NC
Practice Address - Zip Code:28754
Practice Address - Country:US
Practice Address - Phone:828-712-7085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer