Provider Demographics
NPI:1124413760
Name:MACK FAMILY CHIRO
Entity Type:Organization
Organization Name:MACK FAMILY CHIRO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-641-8352
Mailing Address - Street 1:1042 N HIGLEY RD STE 102-442
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-5398
Mailing Address - Country:US
Mailing Address - Phone:480-641-8352
Mailing Address - Fax:
Practice Address - Street 1:6020 E BROWN RD STE 104
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4812
Practice Address - Country:US
Practice Address - Phone:480-641-8352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2015015-01-BE111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ64783Medicare PIN