Provider Demographics
NPI:1649390352
Name:VANDECASTLE, MARK JAMES (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:VANDECASTLE
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 1:140 N. TOWNLINE RD
Mailing Address - Street 2:PO BOX 246
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-0246
Mailing Address - Country:US
Mailing Address - Phone:920-787-0122
Mailing Address - Fax:920-787-0091
Practice Address - Street 1:140 N. TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-0246
Practice Address - Country:US
Practice Address - Phone:920-787-0122
Practice Address - Fax:920-787-0091
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3211-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35249Medicare ID - Type Unspecified
WIU53610Medicare UPIN