Healthcare Provider Details

I. General information

NPI: 1699409367
Provider Name (Legal Business Name): MARK MENSCH ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2022
Last Update Date: 07/10/2022
Certification Date: 07/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 MASTIC RD STE 4
MASTIC BEACH NY
11951-1020
US

IV. Provider business mailing address

PO BOX 407
MORICHES NY
11955-0407
US

V. Phone/Fax

Practice location:
  • Phone: 631-281-3871
  • Fax:
Mailing address:
  • Phone: 631-375-5241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number000232
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: