Provider Demographics
NPI:1720085632
Name:PENSIS, MARK JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:PENSIS
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 1:275 S MAIN ST
Mailing Address - Street 2:P. O. BOX 266
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-1604
Mailing Address - Country:US
Mailing Address - Phone:715-823-2912
Mailing Address - Fax:715-823-1331
Practice Address - Street 1:275 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1604
Practice Address - Country:US
Practice Address - Phone:715-823-2912
Practice Address - Fax:715-823-1331
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2292-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38833800Medicaid
WI391524586016OtherBLUE CROSS/BLUE SHIELD
WI38833800Medicaid