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General NPI Number Information
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NPI Number | 1508310244
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Entity Type | Individual
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Provider Name | MICHAEL DAVID MARK LA.C, DIPL. O.M.
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Gender | Male
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Dates
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Enumeration Date | 08/11/2016
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Last Update Date | 08/11/2016
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Provider Practice Location Address
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Address Line | 13677 FOOTHILL BLVD STE P
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City | FONTANA
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State | CA
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Zip | 92335-0214
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Country | US
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Telephone | 909-766-5397
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Fax | 909-697-2274
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Provider Business Mailing Address
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Address Line | 20687 AMAR ROAD STE 2 BOX 240
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City | WALNUT
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State | CA
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Zip | 91789
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Country | US
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Telephone | 909-766-5397
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Fax | 909-697-2274
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 17044
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License Number State | CA
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