Provider Demographics
NPI:1811037864
Name:LUELL, MARK DOUGLAS SR (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:LUELL
Suffix:SR
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 1:5150 ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:STONE MTN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-4248
Mailing Address - Country:US
Mailing Address - Phone:770-469-2210
Mailing Address - Fax:
Practice Address - Street 1:1344 ROCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:STONE MTN
Practice Address - State:GA
Practice Address - Zip Code:30087-3138
Practice Address - Country:US
Practice Address - Phone:770-923-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001417111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor