Healthcare Provider Details

I. General information

NPI: 1679729859
Provider Name (Legal Business Name): BRENDA MACK ST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 HARDING RD STE 300
NASHVILLE TN
37205-2013
US

IV. Provider business mailing address

PO BOX 253
COTTONTOWN TN
37048-0253
US

V. Phone/Fax

Practice location:
  • Phone: 615-783-1269
  • Fax:
Mailing address:
  • Phone: 615-230-1892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: