Provider Demographics
NPI:1114996717
Name:MEDEIROS, MARK (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MEDEIROS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 PLEASANT ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-3005
Mailing Address - Country:US
Mailing Address - Phone:508-677-0733
Mailing Address - Fax:508-646-7641
Practice Address - Street 1:289 PLEASANT ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-3005
Practice Address - Country:US
Practice Address - Phone:508-677-0733
Practice Address - Fax:508-646-7641
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1523111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T93458Medicare UPIN
Y36063Medicare PIN