Healthcare Provider Details

I. General information

NPI: 1609315571
Provider Name (Legal Business Name): MARK J STUBBENDIECK DC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 E SMITH RD # A
MEDINA OH
44256-2662
US

IV. Provider business mailing address

780 E SMITH RD # A
MEDINA OH
44256-2662
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-4060
  • Fax: 330-722-4582
Mailing address:
  • Phone: 133-072-5406
  • Fax: 330-722-4582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1935
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number1935
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1935
License Number StateOH

VIII. Authorized Official

Name: DR. MARK STUBBENDIECK
Title or Position: OWNER
Credential: DC
Phone: 330-725-4060