Provider Demographics
NPI:1659410454
Name:MIELKE, MARK ALEXANDER (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALEXANDER
Last Name:MIELKE
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 1:5630 3RD ST
Mailing Address - Street 2:P.O. BOX 2098
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248
Mailing Address - Country:US
Mailing Address - Phone:360-380-4848
Mailing Address - Fax:360-384-7416
Practice Address - Street 1:5630 3RD ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248
Practice Address - Country:US
Practice Address - Phone:360-380-4848
Practice Address - Fax:360-384-7416
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003092111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor