Healthcare Provider Details

I. General information

NPI: 1700398690
Provider Name (Legal Business Name): FELICIA M MACK PCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: FELICIA BROWN PCA

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 KENDRICK ESTATES DR
JONESBORO GA
30238-2196
US

IV. Provider business mailing address

307 KENDRICK ESTATES DR
JONESBORO GA
30238-2196
US

V. Phone/Fax

Practice location:
  • Phone: 678-758-2092
  • Fax:
Mailing address:
  • Phone: 678-758-2092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: