Provider Demographics
NPI:1992125496
Name:MYERS, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MYERS
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 1:7 LINNEA LANE
Mailing Address - Street 2:
Mailing Address - City:NORTHE CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 LINNEA LN
Practice Address - Street 2:
Practice Address - City:NORTH CHILI
Practice Address - State:NY
Practice Address - Zip Code:14514-9725
Practice Address - Country:US
Practice Address - Phone:585-314-5638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY670020662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer