Healthcare Provider Details

I. General information

NPI: 1780136192
Provider Name (Legal Business Name): MARK GREG IWANICKI ND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 THROCKMORTON AVE
MILL VALLEY CA
94941-1909
US

IV. Provider business mailing address

355 VALDEZ AVE
SAN FRANCISCO CA
94127-2123
US

V. Phone/Fax

Practice location:
  • Phone: 917-971-6625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: