1104327493 NPI number — MACK CHIROPRACTIC

Table of content: YESSENIA NUNEZ-GONZALEZ (NPI 1528542834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104327493 NPI number — MACK CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACK CHIROPRACTIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104327493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5160 RIVES JUNCTION RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49201-9453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-990-4163
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 W MICHIGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49202-1805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-748-7799
Provider Business Practice Location Address Fax Number:
833-300-9391
Provider Enumeration Date:
02/22/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MACK
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
KIRK
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
517-748-7799

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301010285 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1386034486 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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