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NPI Code Detail

MEDICARE: STACY MACK PTA

MEDICARE: STACY MACK PTA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225200000XPhysical Therapy AssistantPTA 05127OH

General Provider Information

NPI Number : 1205035789
Entity Type Code : Individual
Provider Name (Legal Business Name) : STACY MACK PTA
Provider Business Mailing Address
First Line : 3425 EXECUTIVE PKWY
Second Line : SUITE 128
City : TOLEDO
State : OH
Zip : 43606-1326
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 11000 STATE ROUTE 347
Second Line :
City : EAST LIBERTY
State : OH
Zip : 43319-9470
Country : US
Telephone Number : 937-578-0598
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/13/2007
Last Update Date : 07/13/2007

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Directions to “ STACY MACK PTA” Practice Location

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