MEDICARE: JOHN AFURONG MACK JR. PT

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	225100000X	Physical Therapist	PT 30285	CA

General Provider Information

NPI Number	:	1831169119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN AFURONG MACK JR. PT

Provider Business Mailing Address
First Line	:	1353 WAYNE WAY
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-1565
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1353 WAYNE WAY
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-1565
Country	:	US
Telephone Number	:	650-345-2739
Fax Number	:

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

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	07/08/2007

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