Healthcare Provider Details

I. General information

NPI: 1083881437
Provider Name (Legal Business Name): ROBERT MACK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SOUTH 74
FT SMITH AR
72902
US

IV. Provider business mailing address

2712 EDGEWATER DRIVE
GREENWOOD AR
72936
US

V. Phone/Fax

Practice location:
  • Phone: 479-478-5572
  • Fax: 479-478-5560
Mailing address:
  • Phone: 479-414-1190
  • Fax: 479-478-5560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTR940
License Number StateAR

VIII. Authorized Official

Name: MR. ROBERT GARY MACK II
Title or Position: PRESIDENT
Credential: OTRL
Phone: 479-414-1190