Healthcare Provider Details

I. General information

NPI: 1902076482
Provider Name (Legal Business Name): MARK FLANNERY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 WILLIAMS ST SUITE 250
SIMI VALLEY CA
93065-2859
US

IV. Provider business mailing address

1919 WILLIAMS ST SUITE 250
SIMI VALLEY CA
93065-2859
US

V. Phone/Fax

Practice location:
  • Phone: 805-991-7455
  • Fax: 805-991-7466
Mailing address:
  • Phone: 805-991-7455
  • Fax: 805-991-7466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number30513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: