MEDICARE: M.A. C. UNLIMITED, LLC

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1619121514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M.A. C. UNLIMITED, LLC

Provider Business Mailing Address
First Line	:	5017 TENNESSEE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63111-1623
Country	:	US
Telephone Number	:	314-766-7198
Fax Number	:

Provider Business Practice Location Address
First Line	:	5017 TENNESSEE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63111-1623
Country	:	US
Telephone Number	:	314-766-7198
Fax Number	:

Authorized Official
Title or Position	:	C.E.O.
Name	:	MR. LAMONT KOLLORE
Credential	:
Telephone Number	:	314-766-7198

Provider Enumeration Date	:	11/05/2008
Last Update Date	:	11/05/2008

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