Provider Demographics
NPI:1538734876
Name:MACK, FRANK
Entity type:Individual
Prefix:
First Name:FRANK
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1715
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31202-1715
Mailing Address - Country:US
Mailing Address - Phone:478-284-6826
Mailing Address - Fax:
Practice Address - Street 1:277 MLK BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-284-6826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6213-1706-6535-7312405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty