1326332834 NPI number — MR. CARL MACK MASSENGALE II CSA

Table of content: MR. CARL MACK MASSENGALE II CSA (NPI 1326332834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326332834 NPI number — MR. CARL MACK MASSENGALE II CSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASSENGALE
Provider First Name:
CARL
Provider Middle Name:
MACK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
II
Provider Credential Text:
CSA
Provider Gender Code:
M

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:
1326332834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1904 FISHER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MULDROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74948-2704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-883-7286
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1904 FISHER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MULDROW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74948-2704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-883-7286
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 246ZC0007X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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