Provider Demographics
NPI:1619926995
Name:SHIRLEY, MARK COLEMAN (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:COLEMAN
Last Name:SHIRLEY
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 1:612 SAINT ANDREWS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5120
Mailing Address - Country:US
Mailing Address - Phone:803-772-7626
Mailing Address - Fax:803-772-7659
Practice Address - Street 1:612 SAINT ANDREWS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5120
Practice Address - Country:US
Practice Address - Phone:803-772-7626
Practice Address - Fax:803-772-7659
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2245111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2245Medicaid
SCU94446Medicare UPIN