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NPI Code Detail

MEDICARE: ANNETTE MACK PTA

MEDICARE: ANNETTE MACK PTA
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
1225200000XPhysical Therapy Assistant2061100TX

General Provider Information

NPI Number : 1871981738
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANNETTE MACK PTA
Provider Business Mailing Address
First Line : 1400 N MAIN ST
Second Line :
City : GIDDINGS
State : TX
Zip : 78942-1360
Country : US
Telephone Number : 979-542-1755
Fax Number :
Provider Business Practice Location Address
First Line : 1400 N MAIN ST
Second Line :
City : GIDDINGS
State : TX
Zip : 78942-1360
Country : US
Telephone Number : 979-542-1755
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/30/2014
Last Update Date : 12/30/2014

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