Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CHIA-1645 | ID |
NPI | 1609365626 |
---|---|
Provider Name | Mark Mead |
First Address | Coeur D Alene, ID 83815-9405 |
Second Address | Coeur D Alene, ID 83815-9405 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2018 |
Last Update Date | 04/05/2018 |