Provider Demographics
NPI:1427090513
Name:LUNGREN, MARK PETER (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PETER
Last Name:LUNGREN
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 1:1850 FLORAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-2808
Mailing Address - Country:US
Mailing Address - Phone:559-896-3075
Mailing Address - Fax:559-896-3077
Practice Address - Street 1:1850 FLORAL AVENUE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-2808
Practice Address - Country:US
Practice Address - Phone:559-896-3075
Practice Address - Fax:559-896-3077
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27808111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0278080Medicaid
CADC027808Medicare ID - Type Unspecified
CADC0278080Medicaid