Healthcare Provider Details

I. General information

NPI: 1053527846
Provider Name (Legal Business Name): CAROL MARIE MACK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3835 CLARIDGE OVAL
UNIVERSITY HEIGHTS OH
44118-4739
US

IV. Provider business mailing address

3835 CLARIDGE OVAL
UNIVERSITY HEIGHTS OH
44118-4739
US

V. Phone/Fax

Practice location:
  • Phone: 440-759-4828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberPT.011577
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: