MEDICARE: MARK THERIAULT D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2346	NC

General Provider Information

NPI Number	:	1437159746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK THERIAULT D.C.

Provider Business Mailing Address
First Line	:	PO BOX 1375
Second Line	:
City	:	DENVER
State	:	NC
Zip	:	28037-2004
Country	:	US
Telephone Number	:	704-489-2273
Fax Number	:	704-489-2274

Provider Business Practice Location Address
First Line	:	1895 N HIGHWAY 16
Second Line	:
City	:	DENVER
State	:	NC
Zip	:	28037-8642
Country	:	US
Telephone Number	:	704-489-2273
Fax Number	:	704-489-2274

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	03/22/2010

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Directions to “ MARK THERIAULT D.C.” Practice Location

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