Provider Demographics
NPI:1710355235
Name:DUNLAP, MARK LEE (ND, CAC, LMT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEE
Last Name:DUNLAP
Suffix:
Gender:M
Credentials:ND, CAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 PARK AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2170
Mailing Address - Country:US
Mailing Address - Phone:208-678-7811
Mailing Address - Fax:208-678-7811
Practice Address - Street 1:2311 PARK AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2170
Practice Address - Country:US
Practice Address - Phone:208-678-7811
Practice Address - Fax:208-678-7811
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACC-89171100000X
ID175F00000X
IDMASG-354225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist