Healthcare Provider Details

I. General information

NPI: 1932389640
Provider Name (Legal Business Name): MARK D NEWCOMER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BROADWAY ST
GALENA IL
61036-1902
US

IV. Provider business mailing address

400 BROADWAY ST
GALENA IL
61036-1902
US

V. Phone/Fax

Practice location:
  • Phone: 815-777-0042
  • Fax: 815-777-0043
Mailing address:
  • Phone: 815-777-0042
  • Fax: 815-777-0043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: