Provider Demographics
NPI:1861487043
Name:STREET, MARK HENRY (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HENRY
Last Name:STREET
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 1:1381 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-3314
Mailing Address - Country:US
Mailing Address - Phone:707-433-5494
Mailing Address - Fax:
Practice Address - Street 1:1381 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3314
Practice Address - Country:US
Practice Address - Phone:707-431-8234
Practice Address - Fax:707-431-1427
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19619111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor