Provider Demographics
NPI:1609315571
Name:MARK J STUBBENDIECK DC INC
Entity Type:Organization
Organization Name:MARK J STUBBENDIECK DC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:STUBBENDIECK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:330-725-4060
Mailing Address - Street 1:780 E SMITH RD # A
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2662
Mailing Address - Country:US
Mailing Address - Phone:133-072-5406
Mailing Address - Fax:330-722-4582
Practice Address - Street 1:780 E SMITH RD # A
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2662
Practice Address - Country:US
Practice Address - Phone:330-725-4060
Practice Address - Fax:330-722-4582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1935111N00000X, 111NR0400X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2657665Medicaid
OH2657665Medicaid