Provider Demographics
NPI:1083881437
Name:ROBERT MACK INC
Entity Type:Organization
Organization Name:ROBERT MACK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:MACK
Authorized Official - Suffix:II
Authorized Official - Credentials:OTRL
Authorized Official - Phone:479-414-1190
Mailing Address - Street 1:2712 EDGEWATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936
Mailing Address - Country:US
Mailing Address - Phone:479-414-1190
Mailing Address - Fax:479-478-5560
Practice Address - Street 1:1801 SOUTH 74
Practice Address - Street 2:
Practice Address - City:FT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72902
Practice Address - Country:US
Practice Address - Phone:479-478-5572
Practice Address - Fax:479-478-5560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR940225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146815742Medicaid