Provider Demographics
NPI:1316094725
Name:REDWINE, MARK THOMAS (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:REDWINE
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 1:500 S MONTANA ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-2418
Mailing Address - Country:US
Mailing Address - Phone:406-723-1230
Mailing Address - Fax:406-723-1230
Practice Address - Street 1:500 S MONTANA ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2418
Practice Address - Country:US
Practice Address - Phone:406-723-1230
Practice Address - Fax:406-723-1230
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT728111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist