Healthcare Provider Details

I. General information

NPI: 1639320179
Provider Name (Legal Business Name): MARK G. MITCHELL, OD, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 KIETZKE LN STE B119
RENO NV
89502-5036
US

IV. Provider business mailing address

4600 KIETZKE LN STE B119
RENO NV
89502-5036
US

V. Phone/Fax

Practice location:
  • Phone: 775-825-0506
  • Fax: 775-825-0873
Mailing address:
  • Phone: 775-825-0506
  • Fax: 775-825-0873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number374
License Number StateNV

VIII. Authorized Official

Name: DR. MARK MITCHELL
Title or Position: CEO
Credential: OD
Phone: 775-825-0506