Provider Demographics
NPI:1215294962
Name:HAINES, MARK JOHN (ATC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:HAINES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 LANCASHIRE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-3275
Mailing Address - Country:US
Mailing Address - Phone:609-261-8824
Mailing Address - Fax:
Practice Address - Street 1:520 JACKSONVILLE ROAD
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-1239
Practice Address - Country:US
Practice Address - Phone:609-267-0837
Practice Address - Fax:609-702-0835
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT00001900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist