Provider Demographics
NPI:1225193147
Name:MACK, CLIFTON GUY (DC)
Entity Type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:GUY
Last Name:MACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5761 E BROWN RD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4449
Mailing Address - Country:US
Mailing Address - Phone:480-641-8352
Mailing Address - Fax:480-641-0541
Practice Address - Street 1:5761 E BROWN RD
Practice Address - Street 2:SUITE 23
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4449
Practice Address - Country:US
Practice Address - Phone:480-641-8352
Practice Address - Fax:480-641-0541
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6098111N00000X
AZ3683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
861002428Medicare UPIN
64783Medicare ID - Type Unspecified