Provider Demographics
NPI:1861265860
Name:MACK, TROY ELGIN JR (PRC)
Entity type:Individual
Prefix:MR
First Name:TROY
Middle Name:ELGIN
Last Name:MACK
Suffix:JR
Gender:M
Credentials:PRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6273 W JEWELL AVE # 109
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-7113
Mailing Address - Country:US
Mailing Address - Phone:720-829-3093
Mailing Address - Fax:
Practice Address - Street 1:6273 W JEWELL AVE # 109
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232-7113
Practice Address - Country:US
Practice Address - Phone:720-829-3093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO07-112-1217175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist