Provider Demographics
NPI:1578572160
Name:MASON, MARIE S (DC)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:S
Last Name:MASON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 W MAIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1715
Mailing Address - Country:US
Mailing Address - Phone:304-842-0601
Mailing Address - Fax:304-842-0602
Practice Address - Street 1:154 W MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1715
Practice Address - Country:US
Practice Address - Phone:304-842-0601
Practice Address - Fax:304-842-0602
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2202005000Medicaid
WV2202005000Medicaid
WV4039981Medicare PIN