Provider Demographics
NPI:1891038642
Name:PENDERGRASS, MARK JACOB (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JACOB
Last Name:PENDERGRASS
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 1:325 SAM RIDLEY PKWY W
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-5625
Mailing Address - Country:US
Mailing Address - Phone:615-239-0907
Mailing Address - Fax:
Practice Address - Street 1:325 SAM RIDLEY PKWY W
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5625
Practice Address - Country:US
Practice Address - Phone:615-239-0907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-30
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2587111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor