Provider Demographics
NPI:1871869289
Name:MARK J STUBBENDIECK DC INC
Entity type:Organization
Organization Name:MARK J STUBBENDIECK DC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:STUBBENDIECK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:330-725-4060
Mailing Address - Street 1:257 S COURT ST
Mailing Address - Street 2:STE 5A
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2295
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:257 S COURT ST
Practice Address - Street 2:STE 5A
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2295
Practice Address - Country:US
Practice Address - Phone:330-725-4060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1935111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2657665Medicaid
OH0740282Medicare UPIN