Provider Demographics
NPI:1538266432
Name:MACK, BRYAN (DC)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18924 EVANS ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022
Mailing Address - Country:US
Mailing Address - Phone:531-466-8611
Mailing Address - Fax:531-999-3842
Practice Address - Street 1:18924 EVAN ST.
Practice Address - Street 2:SUITE 105
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022
Practice Address - Country:US
Practice Address - Phone:531-466-8611
Practice Address - Fax:531-999-3842
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7473111N00000X
NE2018111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0941700OtherBCBS PROVIDER ID
AZAZ0941700OtherBCBS PROVIDER ID
AZV00814Medicare UPIN
AZZ137405Medicare PIN
AZZ92658Medicare PIN