Provider Demographics
NPI:1184816886
Name:MACK, LESTER EVERTON
Entity Type:Individual
Prefix:
First Name:LESTER
Middle Name:EVERTON
Last Name:MACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36000 DARNALL LOOP
Mailing Address - Street 2:CARL R DARNALL ARMY MEDICAL CENTER
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5095
Mailing Address - Country:US
Mailing Address - Phone:254-553-2278
Mailing Address - Fax:
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:CARL R DARNALL ARMY MEDICAL CENTER
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-553-2278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR145833163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult