Healthcare Provider Details

I. General information

NPI: 1265377915
Provider Name (Legal Business Name): MACK J NEAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W GRIGGS AVE
LAS CRUCES NM
88001-1234
US

IV. Provider business mailing address

1990 FENTON ST APT 13
LAKEWOOD CO
80214-1646
US

V. Phone/Fax

Practice location:
  • Phone: 575-277-9318
  • Fax:
Mailing address:
  • Phone: 505-390-3379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: