Provider Demographics
NPI:1699842385
Name:BENNALLACK, MARK WILLIAM (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:BENNALLACK
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 1:1234 W CHAPMAN AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2862
Mailing Address - Country:US
Mailing Address - Phone:714-289-4693
Mailing Address - Fax:714-289-4698
Practice Address - Street 1:1234 W CHAPMAN AVE
Practice Address - Street 2:SUITE # 204
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2862
Practice Address - Country:US
Practice Address - Phone:714-289-4693
Practice Address - Fax:714-289-4698
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22589111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician