Provider Demographics
NPI:1114063708
Name:DEDERICHS, MARK MITCHELL (DC LAC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:MITCHELL
Last Name:DEDERICHS
Suffix:
Gender:M
Credentials:DC LAC
Other - Prefix:
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Mailing Address - Street 1:1435 E RT 66
Mailing Address - Street 2:#C
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740
Mailing Address - Country:US
Mailing Address - Phone:626-963-6332
Mailing Address - Fax:626-963-0262
Practice Address - Street 1:1435 E RT 66
Practice Address - Street 2:#C
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-3748
Practice Address - Country:US
Practice Address - Phone:626-963-6332
Practice Address - Fax:626-963-0262
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA16330111N00000X
CA9187171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist