Provider Demographics
NPI:1780480244
Name:MACK, GLORIA PATRICIA (NDTR)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:PATRICIA
Last Name:MACK
Suffix:
Gender:F
Credentials:NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 DR MARTIN LUTHER KING BLVD APT 7E
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-4125
Mailing Address - Country:US
Mailing Address - Phone:914-263-1860
Mailing Address - Fax:
Practice Address - Street 1:130 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3904
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered