Healthcare Provider Details

I. General information

NPI: 1588209365
Provider Name (Legal Business Name): CHARLIE MACK II EP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 PARK BLVD
SEMINOLE FL
33777-4119
US

IV. Provider business mailing address

1745 S HIGHLAND AVE
CLEARWATER FL
33756-1852
US

V. Phone/Fax

Practice location:
  • Phone: 727-545-4545
  • Fax: 727-548-1360
Mailing address:
  • Phone: 727-767-0955
  • Fax: 727-587-0527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: