Provider Demographics
NPI:1942416185
Name:BETTENCOURT, MARK DAMON (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAMON
Last Name:BETTENCOURT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7413 N CEDAR AVE
Mailing Address - Street 2:SUITE101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3833
Mailing Address - Country:US
Mailing Address - Phone:559-437-9405
Mailing Address - Fax:559-439-4620
Practice Address - Street 1:7413 N CEDAR AVE
Practice Address - Street 2:SUITE101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3833
Practice Address - Country:US
Practice Address - Phone:559-437-9405
Practice Address - Fax:559-439-4620
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26843111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0268430Medicare ID - Type Unspecified