Provider Demographics
NPI:1508310244
Name:MARK, MICHAEL DAVID (LAC, DIPL OM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:MARK
Suffix:
Gender:M
Credentials:LAC, DIPL OM
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:20687 AMAR ROAD STE 2 BOX 240
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789
Mailing Address - Country:US
Mailing Address - Phone:909-766-5397
Mailing Address - Fax:909-697-2274
Practice Address - Street 1:13677 FOOTHILL BLVD STE P
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-0214
Practice Address - Country:US
Practice Address - Phone:909-766-5397
Practice Address - Fax:909-697-2274
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA17044171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist