Healthcare Provider Details

I. General information

NPI: 1548184070
Provider Name (Legal Business Name): MR. LANCE MACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 E HOSPITALITY LN STE 400
SAN BERNARDINO CA
92408-3545
US

IV. Provider business mailing address

4437 UNIVERSITY AVE APT 1
RIVERSIDE CA
92501-3184
US

V. Phone/Fax

Practice location:
  • Phone: 909-891-1599
  • Fax:
Mailing address:
  • Phone: 661-345-1487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: