Provider Demographics
NPI:1497180319
Name:MACK, CEDRIC L
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:L
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 1:6666 W WASHINGTON AVE
Mailing Address - Street 2:SUITE 493
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1349
Mailing Address - Country:US
Mailing Address - Phone:404-981-3563
Mailing Address - Fax:
Practice Address - Street 1:6889 S EASTERN AVENUE,
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119
Practice Address - Country:US
Practice Address - Phone:702-434-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health