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General NPI Number Information
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NPI Number | 1053565648
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Entity Type | Organization
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Legal Business Name | MACTA, LLC
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Dates
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Enumeration Date | 11/09/2008
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Last Update Date | 01/16/2009
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Provider Practice Location Address
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Address Line | 450 S WESLEYAN BLVD
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City | ROCKY MOUNT
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State | NC
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Zip | 27803-1700
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Country | US
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Telephone | 252-443-0836
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Fax | 252-443-0836
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Provider Business Mailing Address
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Address Line | 1012 SANDBERG LN
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City | ROCKY MOUNT
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State | NC
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Zip | 27803-2253
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Country | US
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Telephone | 252-443-0836
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Fax | 252-443-0836
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | MR. RUSSELL W WOOTEN
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Credential |
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Telephone | 252-443-0836
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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