Provider Demographics
NPI:1528058484
Name:NILES, MARK ANTHONY (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:NILES
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 1:200 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IA
Mailing Address - Zip Code:52772-1851
Mailing Address - Country:US
Mailing Address - Phone:563-886-6900
Mailing Address - Fax:563-886-2380
Practice Address - Street 1:200 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IA
Practice Address - Zip Code:52772-1851
Practice Address - Country:US
Practice Address - Phone:563-886-6900
Practice Address - Fax:563-886-2380
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4975111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA207357Medicaid
IA207357Medicaid