Provider Demographics
NPI:1124105275
Name:SHELLEY, MARK S (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:SHELLEY
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 1:6603 220TH ST SW
Mailing Address - Street 2:STE 102
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-2186
Mailing Address - Country:US
Mailing Address - Phone:425-774-2411
Mailing Address - Fax:425-672-7065
Practice Address - Street 1:6603 220TH ST SW
Practice Address - Street 2:STE 102
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2186
Practice Address - Country:US
Practice Address - Phone:425-774-2411
Practice Address - Fax:425-672-7065
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001890111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2000057Medicaid
WA2000057Medicaid
WAGAB21079Medicare PIN