Provider Demographics
NPI:1992865547
Name:MARK B THOMAS DC PC
Entity Type:Organization
Organization Name:MARK B THOMAS DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DABCI
Authorized Official - Phone:541-942-5024
Mailing Address - Street 1:500 E WHITEAKER AVE
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1648
Mailing Address - Country:US
Mailing Address - Phone:541-942-5024
Mailing Address - Fax:541-942-0598
Practice Address - Street 1:500 E WHITEAKER AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1648
Practice Address - Country:US
Practice Address - Phone:541-942-5024
Practice Address - Fax:541-942-0598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR112284Medicare ID - Type Unspecified