Provider Demographics
NPI:1437857307
Name:MACK, KRISTIN RENAY
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:RENAY
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-9303
Mailing Address - Country:US
Mailing Address - Phone:330-337-9045
Mailing Address - Fax:330-337-9052
Practice Address - Street 1:2875 E STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-9303
Practice Address - Country:US
Practice Address - Phone:330-337-9045
Practice Address - Fax:330-337-9052
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7093-SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician