Provider Demographics
NPI:1982316501
Name:FELICIANO, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FELICIANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HIGH PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4810
Mailing Address - Country:US
Mailing Address - Phone:574-364-1000
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH PARK AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4810
Practice Address - Country:US
Practice Address - Phone:574-364-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered