Healthcare Provider Details

I. General information

NPI: 1861487043
Provider Name (Legal Business Name): MARK HENRY STREET DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1381 UNIVERSITY ST
HEALDSBURG CA
95448-3314
US

IV. Provider business mailing address

1381 UNIVERSITY ST
HEALDSBURG CA
95448-3314
US

V. Phone/Fax

Practice location:
  • Phone: 707-431-8234
  • Fax: 707-431-1427
Mailing address:
  • Phone: 707-433-5494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC19619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: