Healthcare Provider Details

I. General information

NPI: 1114700770
Provider Name (Legal Business Name): MACK VEIN SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 SIERRA ROSE DR STE 4
RENO NV
89511-2093
US

IV. Provider business mailing address

605 SIERRA ROSE DR STE 4
RENO NV
89511-2093
US

V. Phone/Fax

Practice location:
  • Phone: 775-451-1730
  • Fax: 775-451-1713
Mailing address:
  • Phone: 775-451-1730
  • Fax: 775-451-1713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANWAR SELASSIE MACK
Title or Position: PRESIDENT
Credential: MD
Phone: 832-744-0949