Healthcare Provider Details

I. General information

NPI: 1790931426
Provider Name (Legal Business Name): BRIAN MACKIE DVM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 OLD WINERY PL
SACRAMENTO CA
95827-1700
US

IV. Provider business mailing address

9801 OLD WINERY PLACE
SACRAMENTO CA
95827
US

V. Phone/Fax

Practice location:
  • Phone: 916-362-3111
  • Fax: 916-362-0190
Mailing address:
  • Phone: 916-362-3111
  • Fax: 916-362-0190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number5946-050
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License NumberVET 15864
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: