Provider Demographics
NPI:1811994684
Name:RICHERT, MARK (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RICHERT
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 1:16134 LINCOLN HWY E
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:IN
Mailing Address - Zip Code:46774-9628
Mailing Address - Country:US
Mailing Address - Phone:260-249-4764
Mailing Address - Fax:
Practice Address - Street 1:610 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-1995
Practice Address - Country:US
Practice Address - Phone:260-749-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001598111N00000X
IN81000060A171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU55107Medicare UPIN