1538266432 NPI number — DR. BRYAN MACK D.C.

Table of content: DR. BRYAN MACK D.C. (NPI 1538266432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538266432 NPI number — DR. BRYAN MACK D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACK
Provider First Name:
BRYAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1538266432
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18924 EVANS ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
ELKHORN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
531-466-8611
Provider Business Mailing Address Fax Number:
531-999-3842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18924 EVAN ST.
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
ELKHORN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
531-466-8611
Provider Business Practice Location Address Fax Number:
531-999-3842
Provider Enumeration Date:
09/20/2006

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: 111N00000X , with the licence number:  7473 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 2018 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AZ0941700 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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