Provider Demographics
NPI:1982779799
Name:LARUE, MARK S (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:LARUE
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 1:9363 NW FOX HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6372
Mailing Address - Country:US
Mailing Address - Phone:503-292-5060
Mailing Address - Fax:
Practice Address - Street 1:713 W MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4475
Practice Address - Country:US
Practice Address - Phone:360-666-4969
Practice Address - Fax:360-666-4969
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003525111N00000X
OR273381111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA010798011OtherTIN
WAGAB36901Medicare ID - Type UnspecifiedMEDICARE