Healthcare Provider Details

I. General information

NPI: 1417654013
Provider Name (Legal Business Name): MACK MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2023
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S AKERS ST STE 120
VISALIA CA
93277-8306
US

IV. Provider business mailing address

2423 W GREEN ACRES DR
VISALIA CA
93291-4342
US

V. Phone/Fax

Practice location:
  • Phone: 559-365-7147
  • Fax: 559-625-6004
Mailing address:
  • Phone: 559-624-6520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LAMAR MACK
Title or Position: CEO
Credential: MD
Phone: 559-624-6520