Provider Demographics
NPI:1518225804
Name:MEADE, MARK (LAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MEADE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 VENICE BLVD APT 303
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-5926
Mailing Address - Country:US
Mailing Address - Phone:310-503-9300
Mailing Address - Fax:310-503-9300
Practice Address - Street 1:2510 MAIN ST STE 209
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3583
Practice Address - Country:US
Practice Address - Phone:310-503-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14147171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist