Provider Demographics
NPI:1699936724
Name:LUKASIAK, MARK JOHN (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:LUKASIAK
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 1:11819 WILSHIRE BLVD STE 211
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6631
Mailing Address - Country:US
Mailing Address - Phone:310-478-1006
Mailing Address - Fax:
Practice Address - Street 1:11819 WILSHIRE BLVD STE 211
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6631
Practice Address - Country:US
Practice Address - Phone:310-478-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22058111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor