Provider Demographics
NPI:1265585517
Name:COLSTON, MARK JOSEPH (ATC,)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOSEPH
Last Name:COLSTON
Suffix:
Gender:M
Credentials:ATC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:MACKINAW
Mailing Address - State:IL
Mailing Address - Zip Code:61755-8991
Mailing Address - Country:US
Mailing Address - Phone:765-376-2657
Mailing Address - Fax:
Practice Address - Street 1:1501 W BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61625-2417
Practice Address - Country:US
Practice Address - Phone:765-376-2657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000941A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist