Provider Demographics
NPI:1962448209
Name:PIERCE, MARK ALTON SR (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALTON
Last Name:PIERCE
Suffix:SR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12620 BEACH BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7131
Mailing Address - Country:US
Mailing Address - Phone:904-645-0777
Mailing Address - Fax:904-645-3483
Practice Address - Street 1:12620 BEACH BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-7131
Practice Address - Country:US
Practice Address - Phone:904-645-0777
Practice Address - Fax:904-645-3483
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH6451OtherCHIROPRACTIC PHYSICIAN #
FL55291YMedicare PIN
FLU56113Medicare UPIN
FL593630064OtherTAX ID NUMBER