Provider Demographics
NPI:1336036615
Name:PACK, MARTEL L
Entity type:Individual
Prefix:
First Name:MARTEL
Middle Name:L
Last Name:PACK
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 1:5401 TACONY ST BLDG 38K3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19137
Mailing Address - Country:US
Mailing Address - Phone:445-207-6002
Mailing Address - Fax:
Practice Address - Street 1:5401 TACONY ST BLDG 38K3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19137
Practice Address - Country:US
Practice Address - Phone:445-207-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management