Healthcare Provider Details

I. General information

NPI: 1184040552
Provider Name (Legal Business Name): CATHY J MACK HAIR REPLACEMENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 COLUMBIA MALL BLVD STE 189
COLUMBIA SC
29223
US

IV. Provider business mailing address

25 REIDY CT
COLUMBIA SC
29223-8555
US

V. Phone/Fax

Practice location:
  • Phone: 803-477-5243
  • Fax:
Mailing address:
  • Phone: 803-477-5243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: