MEDICARE: MISS TRACY MARCEL MACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1578078432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TRACY MARCEL MACK

Provider Business Mailing Address
First Line	:	1206 PARKVIEW AVE
Second Line	:
City	:	MIDDLETOWN
State	:	OH
Zip	:	45044-5851
Country	:	US
Telephone Number	:	513-915-2106
Fax Number	:

Provider Business Practice Location Address
First Line	:	1239 CENTRAL AVE
Second Line	:
City	:	MIDDLETOWN
State	:	OH
Zip	:	45044-4103
Country	:	US
Telephone Number	:	513-737-1247
Fax Number	:	513-737-3639

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2017
Last Update Date	:	12/13/2017

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Directions to “ MISS TRACY MARCEL MACK ” Practice Location

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