Provider Demographics
NPI:1326754789
Name:MACK XPRESS MEDICAL DIAGNOSTICS AND PHYSICALS
Entity Type:Organization
Organization Name:MACK XPRESS MEDICAL DIAGNOSTICS AND PHYSICALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAKETHIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:678-951-3794
Mailing Address - Street 1:45 PINE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-2561
Mailing Address - Country:US
Mailing Address - Phone:470-507-4444
Mailing Address - Fax:470-878-4788
Practice Address - Street 1:45 PINE GROVE RD
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-2561
Practice Address - Country:US
Practice Address - Phone:470-507-4444
Practice Address - Fax:470-878-4788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service