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General NPI Number Information
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NPI Number | 1083881437
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Entity Type | Organization
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Legal Business Name | ROBERT MACK INC
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Dates
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Enumeration Date | 05/14/2008
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Last Update Date | 05/14/2008
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Provider Practice Location Address
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Address Line | 1801 SOUTH 74
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City | FT SMITH
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State | AR
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Zip | 72902
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Country | US
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Telephone | 479-478-5572
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Fax | 479-478-5560
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Provider Business Mailing Address
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Address Line | 2712 EDGEWATER DRIVE
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City | GREENWOOD
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State | AR
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Zip | 72936
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Country | US
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Telephone | 479-414-1190
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Fax | 479-478-5560
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ROBERT GARY MACK II
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Credential | OTRL
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Telephone | 479-414-1190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | OTR940
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License Number State | AR
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