Healthcare Provider Details

I. General information

NPI: 1619018793
Provider Name (Legal Business Name): ROBERT GARY MACK II BACHELOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2712 EDGEWATER DRIVE
GREENWOOD AR
72936
US

IV. Provider business mailing address

2712 EDGEWATER DRIVE
GREENWOOD AR
72936
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number1002664
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: