Provider Demographics
NPI:1710905484
Name:HEATH, MARK T (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:HEATH
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 1:339 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-1723
Mailing Address - Country:US
Mailing Address - Phone:650-726-5265
Mailing Address - Fax:650-726-1941
Practice Address - Street 1:339 MAIN ST
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-1723
Practice Address - Country:US
Practice Address - Phone:650-726-5265
Practice Address - Fax:650-726-1941
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0171820111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor