Provider Demographics
NPI:1497896054
Name:ALLEN, MARK BOONE (MPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BOONE
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 SAN ANTONIO RD
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-7811
Mailing Address - Country:US
Mailing Address - Phone:949-470-0303
Mailing Address - Fax:949-470-0316
Practice Address - Street 1:15825 LAGUNA CANYON RD STE 103
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2126
Practice Address - Country:US
Practice Address - Phone:949-861-4108
Practice Address - Fax:949-861-4109
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22591225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT22591BMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID #
CAPT22591Medicare ID - Type UnspecifiedSTATE LICENSE NUMBER