Provider Demographics
NPI:1740233949
Name:GARRISON, MARK ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:GARRISON
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 1:627 S CATALINA AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4102
Mailing Address - Country:US
Mailing Address - Phone:424-212-9428
Mailing Address - Fax:424-210-3512
Practice Address - Street 1:25200 CRENSHAW BLVD
Practice Address - Street 2:STE. 101
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6130
Practice Address - Country:US
Practice Address - Phone:424-212-9428
Practice Address - Fax:424-210-3512
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2566111N00000X
CA26721111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6CH356Medicaid
SC6CH356Medicaid