Provider Demographics
NPI:1962895623
Name:MCKINLEY, MARK B (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:DPT
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Mailing Address - Street 1:1115 BOULDERS PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:4710 PUDDLEDOCK RD
Practice Address - Street 2:STE 100
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1269
Practice Address - Country:US
Practice Address - Phone:804-732-0035
Practice Address - Fax:804-732-0045
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2020-10-30
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Provider Licenses
StateLicense IDTaxonomies
SC7559225100000X
VA2305207940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7559OtherLICENSE
VAC09813OtherMEDICARE IDENTIFICATION NUMBER