Provider Demographics
NPI:1760019483
Name:MCKINNEY, MARK (CCP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 HURST DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-1574
Mailing Address - Country:US
Mailing Address - Phone:937-405-8450
Mailing Address - Fax:
Practice Address - Street 1:1520 S MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2643
Practice Address - Country:US
Practice Address - Phone:937-208-7266
Practice Address - Fax:937-208-7242
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist