=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215158662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK E. NIEMCHAK, DC, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 09/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4822 SIX FORKS RD SUITE 104
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-5269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-614-8555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4822 SIX FORKS RD SUITE 104
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-5269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-614-8555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. MARK EMIL NIEMCHAK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 919-614-8555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1469
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------