Healthcare Provider Details

I. General information

NPI: 1649800079
Provider Name (Legal Business Name): TONDALAYA DENISE MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 LEROY STEVENS RD APT35
MOBILE AL
36695
US

IV. Provider business mailing address

1450 LEROY STEVENS RD APT35
MOBILE AL
36695
US

V. Phone/Fax

Practice location:
  • Phone: 251-930-3578
  • Fax:
Mailing address:
  • Phone: 251-930-3578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: