Provider Demographics
NPI:1629259031
Name:DANFORTH, MARK (OMD, LAC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:DANFORTH
Suffix:
Gender:M
Credentials:OMD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 381
Mailing Address - Street 2:
Mailing Address - City:WILBUR
Mailing Address - State:WA
Mailing Address - Zip Code:99185-0381
Mailing Address - Country:US
Mailing Address - Phone:509-766-4334
Mailing Address - Fax:
Practice Address - Street 1:830 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-5932
Practice Address - Country:US
Practice Address - Phone:509-766-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA269171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist