Provider Demographics
NPI:1578610523
Name:NALLEY, MARK LANE (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LANE
Last Name:NALLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4188
Mailing Address - Country:US
Mailing Address - Phone:407-846-2225
Mailing Address - Fax:407-846-6277
Practice Address - Street 1:709 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4188
Practice Address - Country:US
Practice Address - Phone:407-846-2225
Practice Address - Fax:407-846-6277
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7583111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381159000Medicaid
FLU73513Medicare UPIN
FL381159000Medicaid