1710017124 NPI number — MACKMALTER ENTERPRISES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710017124 NPI number — MACKMALTER ENTERPRISES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACKMALTER ENTERPRISES, INC.
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:
6
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:
1710017124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
603 PUBLIC SQUARE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61812-2332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-438-0309
Provider Business Mailing Address Fax Number:
618-438-4406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 RUSHING DRIVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
HERRIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62948-3749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-998-9250
Provider Business Practice Location Address Fax Number:
618-998-9286
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
TAMI
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
618-438-0309

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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