Provider Demographics
NPI:1730816810
Name:MACKE FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:MACKE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:MACKE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP
Authorized Official - Phone:937-492-1352
Mailing Address - Street 1:1025 FAIR RD
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-8947
Mailing Address - Country:US
Mailing Address - Phone:937-492-1352
Mailing Address - Fax:937-492-1353
Practice Address - Street 1:1025 FAIR RD
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-8947
Practice Address - Country:US
Practice Address - Phone:937-492-1352
Practice Address - Fax:937-492-1353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-08
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty